Survey coordinator: 'Point person' for preparedness
Hospitals are increasingly adding new role
Keeping up with the ever-increasing requirements of regulatory and accreditation groups is proving too much for many hospital-based quality professionals. To address this, some hospitals are creating "survey coordinator" roles, with a single individual acting as the point person for accreditation requirements.
During the 2005-2006 budget cycle at Oregon Health & Sciences University Hospitals and Clinics in Portland, a decision was made to centralize the coordination of regulatory readiness into the role of one person. The title for this role is manager of accreditation and regulation, and the former "quality and regulatory program" is now called the "quality program."
"This decision was based largely on the recognized complexity of ongoing readiness for an unannounced Joint Commission survey," says Christine Samuelson Slusarenko, MS, RN, director of medical affairs/quality management/ employee health. "The organization sought one source for readiness planning, messages, and standards interpretation."
One individual reports to this role, a person who historically assumed responsibility for licensure activities and regulatory liaisons with the department of health for the hospitals and clinics. "This has been a natural fit of activities in a reporting relationship," says Slusarenko."
The organization has a medical affairs/quality management department whose scope includes the hospitals and clinics. This department includes quality, infection control, and credentialing, clinical risk and safety, and employee health programs.
Until last year, responsibility for regulatory management issues and readiness for the Joint Commission, CMS, and the state of Oregon's department of health resided with the six quality specialists and their manager, in a quality and regulatory program within the medical affairs/quality management department. Overall direction for readiness and standards interpretation was the responsibility of the department director.
The person recruited for the new role came with many years of regulatory and compliance experience in another health care system and is a clinician. "The first responsibility for this role was the submission of the organization's periodic performance review [PPR] in September 2006," says Slusarenko. "The action plans coming from that submission are now driving the organization's readiness activities."
For the hospital, the new role has been an effective and efficient way to manage, monitor, and communicate ongoing readiness. Since the reporting relationship has remained within the medical affairs/quality management department, responsibility for communication and monitoring of readiness activities has become a natural extension of everyone's role within the department, says Slusarenko.
With one source communicating with the administrative team and medical executive committee, there is increased clarity in the organization's readiness status and necessary action items. Quality specialists are provided weekly information to teach and reinforce as they liaise with the units, ancillary departments, and committees to which they are assigned. "One source refers to the topic or message that is being imparted," says Slusarenko. "Standards are interpreted by one person rather than many."
At Wellspan Health in York, PA, a nurse currently is in training as JCAHO survey coordinator within the quality department. "JCAHO may not be the entire job function within this position," says Sandra Abnett, director of quality. "They may also coordinate the state licensing surveys and could be asked to perform other job functions within the quality department."
The JCAHO survey coordinator works with the clinical support areas, nursing and environment of care directors to coordinate internal monthly meetings to keep up with the clinical and EOC standards, respectively. The role acts as the lead coordinator to help with keeping the team up to date on new standards, coordinating the annual PPR, completing survey application, coordinating correction action plans, and acting as the hospital liaison to JCAHO.
"We feel that at least one person should be the lead person who knows a little about everything, and the point person for everyone at the hospital to contact regarding accreditation," says Abnett.
[For more information, contact:
Sandra Abnett, Director of Quality, Wellspan Health, 1001 South George Street, York, PA 17405-7198. Telephone: (717) 851-5869. E-mail: [email protected].
Christine Samuelson Slusarenko, M.S., R.N, Director, Medical Affairs/Quality Management/ Employee Health, Oregon Health & Science University Hospitals & Clinics, 3181 S.W. Sam Jackson Park Road Mail Code MBS, Portland, OR 97239-3098. Telephone: (503) 494- 6459. Fax: (503) 494-8492. E-mail: [email protected].]
Keeping up with the ever-increasing requirements of regulatory and accreditation groups is proving too much for many hospital-based quality professionals. To address this, some hospitals are creating "survey coordinator" roles, with a single individual acting as the point person for accreditation requirements.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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