Accreditation field report
One facility's answer: always be ready
Laura Sellers, director of operations at Skyland Trail, an 80-bed behavioral health hospital in Atlanta, has gone through 10 Joint Commission surveys. Over time, she has learned an invaluable lesson: Getting ready a few months before the survey was a sure way to drive herself and the rest of the staff crazy.
Taking a leaf out of the Boy Scout handbook, she decided that the best way to prepare was to always be prepared. "You would panic six months before and start cleaning everything up and getting everything ready," she says. "It is not worth all the hassle and drama to do it that way. I think you are better off being ready every day. Incorporate all the things you are supposed to do into your culture and then it doesn't matter when they come, you will always be ready."
The Joint Commission's tracer program means there is no more dusting off binders of policies every three years. You are working with real patients, not pieces of paper.
Her experience last fall did not provide many surprises. There was a big push on suicide risk assessment even bigger than she expected. But Skyland Trail had its policy and assessment ready since it is a mental health facility. "We did have to argue our position. There were some intense discussions, and the focus was more than we anticipated."
The surveyor also spent a lot of time talking with clients six of the 80, one from each of the recovery communities resident in the facility. "It was a high percentage, I thought," Sellers says. The surveyor also spent less time on physical plant issues than one might have thought. Sellers thinks that might be because they had recently remodeled, and thanks to some great donors, the place is really pleasant and attractive. "I don't know how much that figured into his lack of interest, but people are only human and probably respond to environment."
The final report was very complimentary, Sellers says. There were just two areas that she was directed to improve. One was a policy for disaster drill debriefing the emergency management standard talks about four separate areas, and Sellers says the surveyor wanted their form to follow that policy. She called some peers and got samples of their forms and quickly adapted them to her needs.
The second area was in treatment planning. "In our residential program, patients self-administer their medications, and adherence is a problem," she notes. "He wanted us to include medication adherence issues in our treatment plans."
The staff developed an assessment form that tied into medication compliance, adding content and planning training for nurses. Both areas for improvement were completed well before the allotted 60 days were up.
After the surveyor leaves, Sellers always makes sure to let staff know what happened and have a celebration. "Some people only have the CEO and medical director involved in reviewing the report. But I think everyone is involved in getting ready, everyone was part of the survey, so they should come in and see what it says. It makes people feel good, and it helps keep them invested in the process, too."
Better safe than sorry
While Sellers firmly believes in being always ready, she also believes in preparation. A few months before the survey is due, she'll hire someone to come in and do a review or mock survey. "It helps to have someone with fresh eyes look at your organization," she says.
After that, there's nothing to do but try to relax. "There are more than 3,000 standards. Even if you went through them all one at a time, you know that someone will be able to find something you missed. You have to understand that."
Fear of the unknown, worry over who your surveyor will be it can stress out even the most ready organizations. "There is always some document that has to be done, always something that has to be improved, always something you need to catch up on." But Sellers says there can be good stress the kind that makes you work hard to complete something in a collected manner and bad stress that has people snapping at each other and running around with more panic than purpose.
"That is why I emphasize being ready and adhering to the standards. I am really thankful to the commission. I'm sure if it was not for surveys that people would not always do the things they should. And most of the standards are very practical and useful. There is a good reason behind them. That makes it easier to get people to comply."
Stay in touch
Another thing that Sellers does as her survey approaches is to stay in touch with her peer group through an electronic listserv or professional group. What is happening at their organizations may give you a hint at trends and what you should be paying special attention to. Talking to those who have been recently surveyed can keep you from being overwhelmed by giving you specific areas on which you can focus.
If you haven't been ready since the last survey, there is not a lot you can do after you get your seven days notice. "You cannot correct six months of incomplete records in a week," she says. "Having beautiful policies is not good enough. You have to be able to show you are using them. That is the purpose of tracers."
But Sellers does have a couple of last-minute tips. First, she says never answer a question that hasn't been asked. Second, she advises that you never change the shower curtains right before a survey. "I had one surveyor tell me that he cannot stand that new vinyl smell anymore because people always put new shower curtains up before they have a survey."
Then, once the survey is over, keep going as if that surveyor is going to reappear the following week. It will save you grief three years down the road.
For more information on this topic contact Laura Sellers, RHIA, Director of Operations, Skyland Trail. Atlanta, GA. Telephone: (678) 686-5910.
Laura Sellers, director of operations at Skyland Trail, an 80-bed behavioral health hospital in Atlanta, has gone through 10 Joint Commission surveys.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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