Survey Response

1. Survey Response Setting the Stage for a Successful Survey

2. It’s 7:40 a.m. Are You Ready for a Survey? Yep Nope • TJC Extranet is checked daily • Key staff have job action sheets that are regularly reviewed • Key leaders and survey support staff rotate early arrival • All staff and physicians know Code TJC responsibilities • Communication plans have been tested & are solid • Notification that TJC is onsite is when they walk into Administration • Key staff are unavailable and unaware of survey procedures • Staff are caught off guard, confused and nervous • Communication is sketchy & survey news travels slowly www.courtemanche-assocs.com

3. Survey Readiness Process & Plan • Tip: A survey can be made (or not!) in the first 30 minutes – be prepared. • Have a plan - Code TJC • Define expectations & responsibilities • Assign tasks – in writing • Prepare ahead • Survey Ready Cart!!! • Ongoing education at all levels • Board • Medical staff • Leadership • Staff www.courtemanche-assocs.com

4. Plan for the Unannounced Survey • Survey Ready Cart • Orientation to the Organization presentation • Joint Commission required documents • Marketing packet • Local restaurants & points of interest • TIP: This cart should be well maintained, always current & immediately available www.courtemanche-assocs.com

5. Structure, Structure, Structure • Survey Readiness Guide • Key Contact/Phone Numbers – Call Tree Notification System • Job Action Sheets – Key Staff • Job Action Sheets – Unit Specific • Readiness Checklists • Environment of Care • Medical Records • Tracer Documentation Tool • Survey Etiquette (staff & management) • Survey Activity Guide • Standards/SOAR/Related Documents www.courtemanche-assocs.com

6. Job Actions • Operator • Reception Areas • Leadership Team • Directors • Managers • Patient Care Areas • Non Patient Care Areas • Survey Coordinator • Surveyor Escorts • Blitz Leaders • Runners • Security Officer • ADN • Administrative Assistants www.courtemanche-assocs.com

7. Survey Support • Leadership Team • Drivers • Management • Coaches • Staff • Star players • Surveyor Escorts • Guides • Scribes • Documenters • Runners • Assistants • Messengers • Blitz Leaders • Staff support www.courtemanche-assocs.com

8. What’s the Survey Coordinator’s Role During a Survey? • Conductor to staff – Host to Surveyors • Demonstrate leadership • Support colleagues & staff! • Manage Command Center • Assign responsibilities • Be ready – greet surveyors enthusiastically • Be honest – you know what you do – share it! • ALWAYS BE POSITIVE – others will read your body language www.courtemanche-assocs.com

9. What’s the Survey Coordinators Role During a Survey? • You’ll also need to be: • Coach and Facilitator • Mentor and Friend • Compassionate – your colleagues will need it! • Enthusiastic & confident • And … • Stroke your team – acknowledge members of the team – how they are involved • Thank Everyone for their participation! www.courtemanche-assocs.com

10. Surveyor Escorts – What do they do? • Role • Serve as guides for assigned Surveyor • Escort Surveyor on all tracer & other survey activity • Serve as liaison between Surveyor & organization staff • Develop a collegial rapport with Surveyor • Report any and all concerns, potential findings, issues, etc. to Command Center www.courtemanche-assocs.com

11. Surveyor Escorts: What competencies do they need? • The Skill Set • Knowledge of organizational policies & procedures • Good wayfinding abilities • Ability to “read” surveyor body language • Keen communication skills – document tracer activity; share results with Command Center • Good interpersonal skills • A positive approach & commitment to organization!! • A SMILE!! www.courtemanche-assocs.com

12. Surveyor Escorts: What’s the job description? • Specific Survey Tasks: • Guide the way (know the best way to go!) • Interact with Surveyor – respond to requests • Serve as a friendly, reassuring presence for staff • Listen to every word; watch every look; examine body language of Surveyor to determine concerns www.courtemanche-assocs.com

13. Surveyor Escorts: What’s the job description? • Engage in polite, professional conversation throughout survey process – share all the best about your organization • Report at least twice daily (lunch & end of day) to Command Center • Share all findings, anything of concern (i.e., staff unable to answer question, challenging physician interactions, etc.) • Identify developing trends (i.e., two medication reconciliation forms not complete) • Share Surveyor biases (i.e., wanting to see care planning done in a particular way) www.courtemanche-assocs.com

14. Scribe – What’s the job description? • Work collaboratively with Surveyor Escort to guide TJC Surveyors • Be the official documenter of all tracer activity • Use Tracer Documentation Tool to capture comprehensive information on EACH patient tracer. Must have: • Patient label • Staff names • Physician names • Questions asked by Surveyor • Concerning responses by staff • Topic areas reviewed & any concerns/findings www.courtemanche-assocs.com

15. Scribes – What’s the job description? • Deliver Tracer Documentation Tools to Command Center frequently - at least at lunch and end of day • Report significant concerns to Command Center immediately www.courtemanche-assocs.com

16. Scribes • Same skill set as Surveyor Escort • The Skill Set • Knowledge of organizational policies & procedures • Good wayfinding abilities • Ability to “read” surveyor body language • Keen communication skills – document tracer activity; share results with Command Center • Good interpersonal skills • A positive approach & commitment to your organization!! • A SMILE!! • PLUS – good attention to detail www.courtemanche-assocs.com

17. Runners – No running necessary! • Role & Survey Specific Tasks • Provide support & “leg work” for Surveyor Escorts • Pull requested policies • Get staff, management for tracer discussion • Alert other departments of impending visit • Get urgent information to Command Center expeditiously • Call in requests to Command Center www.courtemanche-assocs.com

18. Runners – A special breed • The Skill Set • Ability to be “seen & not heard” • Knowledge of the floor plan • Access to all areas • Knowledge of policy, procedure, resource availability • Understanding of survey process & TJC standards www.courtemanche-assocs.com

19. Blitz Leaders – The Advance People! • Role & Survey Specific Tasks • Provide support & oversight of unit/department staff in assuring constant state of readiness throughout survey • Conduct rounds on assigned units • Ensure environmental sweeps, medical record checks, medication security, patient safety rounds are being done • Provide assistance, support and “cheerleading” to staff & unit management www.courtemanche-assocs.com

20. Leadership – Drives the Event • Team Owners • Set the tone and provide the resources and reassurances necessary to create a positive survey environment • Participate actively throughout survey process – be present to Surveyors • Demonstrate accomplishments & share the vision • Provide honest, frequent feedback www.courtemanche-assocs.com

21. Management – Go Coach! • Participate in survey process • Oversee “job action” responsibilities • Exude positivity & confidence • Provide support, encouragement & praise to staff www.courtemanche-assocs.com

22. Physicians & Staff – Star Players • Demonstrate the high quality, safe care you provide EVERY DAY! • Share all the good initiatives organization is involved in • Show your pride! www.courtemanche-assocs.com

23. Other Key Roles • Security & Reception – greet surveyors; notify Survey Coordinator/Administration • Administrative Assistants – clear conference rooms; contact Leadership; order food! • Operator – predetermined script for call notification & paging • Clinical Managers – assignments; record review; environmental sweeps www.courtemanche-assocs.com

24. Survey Etiquette for Everyone • Welcome the survey team as guests in your home • Respond to what is asked – but no more than that • Be confident & professional • Don’t argue – even if you don’t agree! • Avoid defensiveness – just share what you know • Only provide factual, truthful information • Smile!!! www.courtemanche-assocs.com

25. It’s Survey Day www.courtemanche-assocs.com

26. It’s 7:45 a.m. and They are Here!!! • How will we know that the survey team is here? • www.jointcommission.org checked daily between 6:45 – 7:30 a.m. • Security on alert – arrange parking & greet • Operator notified • Code TJC • Initial alert throughout organization • “Hospital XYZ Welcomes the Joint Commission Survey Team” www.courtemanche-assocs.com

27. Calling in the Team • Calling Tree initiated by Operator (with support as needed) • Survey Coordinator • Organization Executives • Standards Experts (incl. Escorts, Blitz Leaders, Runners) • Directors • Unit/Department call lists activated (develop & assign responsibility) www.courtemanche-assocs.com

28. Activating the Plan • Surveyor Headquarters & Staff Command Center Activated • Surveyor Room • Coffee & Orientation Packets Provided • Required Documentation • Staff Command Center • Surveyor Escorts & Runners – Report for Assignments & Resources www.courtemanche-assocs.com

29. Command Center Established • Calling tree notification implemented • Email notification sent • Seek Survey 911 support from Courtemanche & Associates (arrange before survey!) • Prepare staff headquarters with phones, laptops, etc. • Room staffed throughout the survey (days) to give staff the support they need and respond to all surveyor requests www.courtemanche-assocs.com

30. Command Center Activity • Coordination of Survey Activities: • Creating & Distributing Agenda • What day, what site? • Sessions (all pre-prepared & practiced) • Orientation to the Organization • Competence Assessment • Medical Staff Credentialing/Privileging • Environment of Care/LSC • Medication Management Tracer • Infection Control Tracer • Data System Tracer • Leadership www.courtemanche-assocs.com

31. Organizational Response • Management must set the tone for the survey experience • Staff need to see our confidence & positivity • Conduct unit/department rounds using Checklist • Immediately remove all clutter • Pull out Job Action Sheets and assign responsibilities • Notify all staff & physicians • CHEERLEAD!!!! www.courtemanche-assocs.com

32. Manage the Survey Process • Staff Headquarters • See Key Contact Numbers • All information should go through Command Center • Questions • Concerns (and Uh-Ohs) • Requests • Daily End-of-Day Briefings • Email Updates • TIP: The goal is to mitigate survey findings and demonstrate the excellent care provided every day www.courtemanche-assocs.com

33. Manage Post – Survey Response • Immediately review survey report • Identify opportunities for Clarification • Work with Leadership to share survey results with organization • Celebrate ! ! • Regardless of outcome • Convey your thanks and confidence • Set the stage for needed change www.courtemanche-assocs.com

34. Survey = Opportunity to Demonstrate High quality, Safe Patient Care • The stakes are immeasurable • TJC/CMS/DOH provide the rules based on well-established criteria • Validation of performance • Successful organizations commit to imbedding those standards into the processes required to care for those in our trust www.courtemanche-assocs.com

35. When the survey team arrives, all we should worry about is putting on the coffee & straightening the magazines!!! www.courtemanche-assocs.com

36. Courtemanche & Associates extends special thanks to Saint Clare’s Health System, Denville, New Jersey for Sharing the Concept for TJC Basic Training and Mobilization Plan www.courtemanche-assocs.com

37. Questions? Contact Us At: Info@courtemanche-assocs.com (704) 573-4535