Hospital wasn’t shooting for 100
Every health care provider undergoing a survey by the Joint Commission on Accreditation of Healthcare Organizations wants the best score possible; but in reality, most just are hoping they don’t get any Type I recommendations and walk away with their accreditation intact. What if you want to do better than that? Can you really shoot for a perfect 100 on your survey?
It’s a high goal to set, but it can be done. And if your organization gets that perfect 100, it will be able to crow about it for quite a while, showing it off in your community as proof that you are among the very best when it comes to health care quality. When Olympic Memorial Hospital in Port Angeles, WA, recently scored a perfect 100 on its survey, leaders there were shocked, albeit quite pleasantly, because they had not made a perfect score the goal of their quality programs. But what they found out was that focus and hard work can make the difference between mere accreditation and a perfect score.
The process began in 1999 after the hospital’s last triennial survey, says Maureen Guzman, RN, director of quality and strategic value at the hospital. At that time, the hospital scored an 89 on its survey and received four Type I recommendations — two related to human resources, one in information management, and one concerning medication security. The hospital received its accreditation, and the 89 score is exactly the national average, nothing to be ashamed of at all. Even the Type Is could be addressed, but that wasn’t enough for Guzman and others at the 126-bed acute care facility with outpatient services and a 125-bed skilled nursing facility.
"We were organizationally not very happy with the score we received and felt like we were a better organization than the score indicated," she says. "At that time, we vowed to do things differently and prepare for the next survey. We wanted to do a lot better."
Guzman joined the hospital soon after the 1999 Joint Commission visit, so one of her first tasks was to address the problems found in the survey. But she and the other hospital leaders took on much more.
Three years later, the hospital joined an elite group of facilities that have scored a perfect 100. Less than 1% of the 4,765 hospitals accredited by the Joint Commission score a 100 on their surveys, according to Charlene Hill, spokeswoman for the accrediting body. She says the Joint Commission actually discourages focusing too much on the numerical score, but she acknowledges that a 100 score is a mark of excellence.
Olympic Memorial trumpets the perfect score in marketing materials, showing it off as a point of pride and a guarantee of quality for patients. Mike Glenn, CEO, says the perfect 100 score is something that patients can understand easily, even if they don’t know much about the Joint Commission. "Too often, the public reads about hospitals that are not performing up to patients’ expectations," he says. "With our 100% score, patients know how serious we are about the quality of our care."
As of June, 67 hospitals in Washington had been surveyed by the Joint Commission, according to information supplied by the accrediting body. The average score in that state was 90, with a range of scores from 76 to Olympic Memorial’s 100. Leo Greenawalt, CEO of the Washington State Hospital Association in Seattle, says the score is worth crowing about.
"Frankly, in my 21 years of hospital association work, I’ve never known of a hospital to get 100%," he says. "This is an incredible accomplishment."
Nationally, the average score for all surveyed facilities is 89, Hill says. So that additional 11 points is the tough part, and Guzman says she and her staff had to work hard to cover that ground. The first step, as it always is with quality improvement projects, was to get buy-in from the hospital leadership. Thirteen top-ranking hospital leaders committed to improving quality and improving the score in the next Joint Commission survey. Their main goal was to create a constant state of readiness in the hospital, with all areas in compliance all the time, so the team was named the "Continuous Accreditation Readiness" team, or CAR. The CAR members took responsibility for 15 different areas in the hospital, such as pharmacology and radiology, setting up subcommittees to continuously monitor and improve compliance.
"In previous years, we had hired a consultant to come in and do a mock survey; then we addressed the deficiencies," Guzman says. "In the new way, we looked at every standard from beginning to end and showed compliance with each one. That made sure we were in compliance, but it also ensured a better knowledge base and helped us be more prepared for the survey."
In addition to hospital leaders, Olympic Memorial was able to bring the hospital’s board of commissioners into the plan. Three members of the board attended leadership and strategic planning meetings, and Guzman helped educate them about the Joint Commission survey process so they could be present and contribute during the survey.
"I spent a lot of time addressing what the surveyor would be asking and how they would ask," she says. "It’s not that the board members wouldn’t know the information, but sometimes the surveyors’ questions are, shall I say, a little bit esoteric. It helped them to know how the questions would be phrased and what the surveyor is looking for."
Every member of the medical staff credentialing unit also participated. The chief of medicine and chief of surgery both were present during the survey. Having those heavy hitters present and ready to participate demonstrates a cohesive structure for the surveyors, Guzman says.
The most recent survey began with a 15-minute meeting with the two surveyors, Guzman, and a few more hospital leaders. Then they began the two-hour document review.
"One thing that was very helpful is that our staff was experienced in previous surveys, so they knew how to put the materials together in a way that was very user-friendly for the surveyor," she says. "The surveyor said this was one of the best document reviews she had ever seen. One said he had never before been able to see everything he wanted to see in the two hours."
To put together such a good presentation, Guzman says you first should go to the Joint Commission web site (www.jcaho.org) and check the information about the survey process. Everything the surveyors want to see is listed there.
"It’s important to put together exactly what they’ve asked for — no more and no less," she says. "Then we put together everything in separate binders by topic and made it easy for the surveyor to find cross-referenced material. Anytime there was a cross-reference to the medical staff bylaws, for instance, the bylaws were right there in the binder for the surveyor to see. We were really trying to make it easy for the surveyor to see, and that’s much appreciated."
After the document review, the surveyor moved on to the performance improvement review. This is the part where the hospital has an opportunity to present a summary of its quality improvement programs and highlight performance measures for the surveyor, but Guzman and her team weren’t sure how long a presentation to prepare. They had heard conflicting accounts in the previous year about how much surveyors wanted to hear, so they played it safe by preparing three different presentations of different lengths.
The 15-minute presentation covered only the most basic information such as ORYX data, and a 30-minute version covered more about quality improvement efforts such as Olympic’s pain management program. The full-hour version covered all of that and more, such as what indicators the hospital chose for measuring its staffing effectiveness and how it chose them.
It turned out that the surveyors wanted the full-hour presentation. The only glitch in the presentation was that the ORYX data in the presentation didn’t jibe with the data that had been transmitted to the Joint Commission already. The cause was a problem with the electronic transmission of the data.
"We ended up having to write a formal letter afterward explaining the variation, but they accepted that," Guzman says. "Pretty much the only question they had at the end of the hour was how well the physicians had accepted the clinical practice guidelines. They didn’t have much to ask about the content of the presentation."
The next step was the leadership and strategic planning meeting with the CEO, other senior leaders, Guzman, three members of the board of commissioners, and the chief of the medical staff. They presented another overview of the hospital’s quality and compliance efforts and fielded the surveyors’ questions.
"We showed our emphasis on patient safety and quality improvement throughout all the entities, and they asked a lot about patient safety," she says. "They also wanted to know a lot about how we’re changing the culture to look more at the process rather than blaming individuals."
After lunch, the surveyors split up and went to different units. They started working their way through the hospital, talking to staff at every opportunity.
"We found that there is a new emphasis by surveyors to talk with line staff," Guzman says. "And it was almost enjoyable to hear them ask and then listen to the responses. In the past, we cringed and hoped the staff knew the answers. But this time, we found that everyone responded with great enthusiasm and with great confidence."
Porcelain Pearls’ in bathroom educated staff
Education efforts in the previous years were paying off for the staff. As part of the overall compliance and quality improvement plan, the hospital took every opportunity to educate staff about Joint Commission compliance. There were the typical meetings and seminars, but one of the most successful efforts was called "Porcelain Pearls." These were "pearls" of wisdom about patient safety, quality, and Joint Commission compliance posted in the bathrooms for staff to see.
"The surveyors said they were never greeted with that deer in the headlights’ look that they’re used to seeing from staff," Guzman says. "The staff had a comfort level with the information and could talk about it easily. That comes from all the education efforts."
Guzman got nervous that evening when she heard that the surveyors had returned after hours to talk to the staff without the leadership team hovering nearby.
"They’re all doing middle-of-the-night surprise visits now," she says. "They’ll ask questions about staffing and competency. I was nervous about how the staff would do, but I was happy with what I heard. They did fine."
Patrice Spath, RHIT, a health care quality and accreditation consultant in Forest Grove, OR, says Joint Commission surveyors now rely on staff input to decide if an organization is in compliance, unlike previous years when formal interviews with selected leaders determined your score. That change makes it very important to educate your staff well before a survey, she says.
"You not only have to educate them on what is going on in the organization, but you also have to educate them in Joint Commission-ese, the language of the standards," she says.
"What you’re doing might be in perfect compliance, but if the staff member doesn’t understand what he’s being asked, he might hesitate or stumble in his answer and give the surveyor the wrong idea," Spath adds.
When the survey was completed, Guzman expected the surveyors to meet only with the CEO to explain the results. She was surprised when they invited her to join the meeting and hear the score.
"The first thing the surveyor said was You’re accredited.’ Then he said there were no Type Is. Then he said there were no supplemental recommendations," she says. "The CEO and I looked at each other like we couldn’t believe it. Then he said we got a 100, and I couldn’t breathe."
The hospital already had received a deficiency-free report from the state department of health earlier in the year, but the hospital’s quality leaders never dreamed they could get a perfect 100 from the Joint Commission. It felt odd to be left without a list of recommendations to work on after the survey, but Guzman says the hospital intends to continue its quality improvement efforts.
"The score was an incredible, pleasant shock," she says. "It was definitely an experience where you look at your career and realize that was a pivotal moment."
[For more information, contact:
- Olympic Memorial Hospital, 939 Caroline St., Port Angeles, WA 98362. Telephone: (360) 417-7000.
- Patrice Spath, Brown-Spath Associates, 2314 19th Ave., Forest Grove, OR 97116. Telephone: (503) 357-9185.]
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