ED Accreditation Update
Take steps to ensure staff are continuously prepared
At Baylor All Saints Medical Center at Fort Worth (TX), the ED managers weren’t taking any chance of being unprepared when the accreditation surveyors showed up for a regular unannounced survey. They set up an interdepartmental team with nurses from the day and night shifts, says Susie Hood, BSN, RN, CNRN, director of emergency services. Hood looked for staff who were well suited for the team because they understood the accreditation process and they were detail-oriented and/or creative.
The team developed questions and answers for games modeled after "Jeopardy" and "Family Feud" that were played for 15 minutes at every staff meeting. At the Family Feud game, for example, staff were divided into two "families," seated on opposite sides of a table, and they competed by answering accreditation questions.
Also, the team members would give spot quizzes to their peers, Hood says. "There was an instant reward," she says. "If they got the answer correct, the team member handed them a prize." Many of the prizes were related to the team’s theme, which was "Lighting the Way to the Joint Commission" and included pen lights, miniature motion lamps, and silly holiday lights. When the staff members answered a second question correctly, they could trade in their prize for a bigger one or keep what they had. "It gave the staff some ownership of the whole process," Hood says. Physicians also were quizzed, she says.
Two staff members were responsible for the environmental side of survey preparation, she says. "They restocked drawers and rearranged drawers so there was consistency in each room," Hood says. Drawers were relabeled so the contents could be seen at a glance, she says. "I’ve never seen an ER so clean," Hood adds.
JCAHO Monthly Topics’
At Aurora Healthcare System in Milwaukee, "JCAHO Monthly Topics" developed by quality management staff were shared with the ED staff within the system, says Rebecca Long, regional director of emergency services. Chapter leaders sent e-mails that spelled out information such as how the different standards or patient safety goals applied to that site, she says.
"What we found was that the more ways we made to normalize the information, to make sure everyone was comfortable and familiar with it, the more relaxed and ready we were," she says. The staff couldn’t walk in the lounge without seeing a "tip of the day," Long says. "It was always in the forefront of our minds, not just getting ready for the review, but we changed our culture to be always ready."
Random unannounced surveys end in 2007
Although the Joint Commission on Accredita-tion of Healthcare Organizations previously announced that random unannounced surveys would continue through 2008, the date for the end of random unannounced surveys has been changed to Dec. 31, 2007.
The Joint Commission has conducted unannounced surveys on a 5% random sample of accredited organizations every year to ensure that demonstrate that organizations remain in compliance with standards throughout the three-year accreditation cycle. Random unannounced surveys are conducted nine to 30 months following the organization’s accreditation date.
The regular surveys conducted for all organizations every three years will continue to be conducted on an unannounced basis.
At Baylor All Saints Medical Center at Fort Worth (TX), the ED managers werent taking any chance of being unprepared when the accreditation surveyors showed up for a regular unannounced survey.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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