For the best results, prepare well for survey
Devote time to perfecting programs, teaching staff
If you want the survey to go smoothly, be prepared, says Megan O’Conner Finch, RNC, MS, patient education coordinator at Union Hospital in Terre Haute, IN.
To make sure the hospital was ready for the patient education portion of the October 1996 survey, O’Conner Finch assembled a multidisciplinary team 21¼2 years ago to prepare staff and make sure policies and programs conformed to standards.
To detect any flaws in the patient education process, the team reviewed what the organization had in place and how it worked including policies, materials, programs, and the evaluation of patient education. Each team member was responsible for working with people in their area to ensure everyone understood the patient education process. The various areas included inpatient, outpatient, physician practices, and therapies.
"Our survey in 1996 was the first survey we had undergone under the new format where the chapters are interdisciplinary. During our last survey, three years ago, each department stood on its own. We worked hard to be ready for that focus on interdisciplinary care," says O’Conner Finch.
Following are several suggestions on how to prepare for the Joint Commission survey:
• Make staff familiar with questions the surveyor might ask.
Prior to the hospital’s August 1996 survey, Jeanne Laws, BSN, patient education coordinator at St. Joseph Regional Medical Center in Lewiston, ID, created several cards with patient education-related questions on the front and the answers on the back. "When I or the other educator was out on a unit, we would stop different disciplines whether the dietitian or physical therapist and have them draw a card and answer the question," explains Laws.
Questions included:
How do you set mutual education goals with the patient?
Where is the patient teaching plan located?
If teaching is not completed in the hospital, what is done about that prior to discharge?
One of those questions also was placed on the hospitalwide computer system once a week so everyone in the hospital would become familiar with the answer.
One year prior to the Joint Commission survey at the University of Wisconsin Hospital and Clinics in Madison, management from various areas took turns posting a sheet that covered information staff needed to know. "It was a way to heighten awareness of all the resources available throughout the hospital and clinics," says Zeena Engelke, RN, MS, senior clinical nurse specialist and Learning Center coordinator at the health system.
• Reinforce compliance with Joint Commission standards.
Because barriers to learning seemed to be a focus of surveyors, Lee Stark, RN, patient education coordinator at Providence Hospital of Alaska in Anchorage, prepared cards that listed barriers to learning that needed to be documented. On the other side of the card, she printed patient rights and responsibilities. The cards were laminated so staff could carry them in their pockets until they became familiar with the information.
Materials aid education
At St. Joseph Medical Center, a six month promotion on age-specific care was conducted. To help staff understand age-specific education, Laws created a booklet on developmental stages. After staff had time to review the material, she conducted a pediatric patient teaching session.
To educate health professionals on how to work with the older adult, she created a poster for each unit. The poster covered common barriers to education such as decreased hearing and the potential for short-term memory loss. It also covered factors that would motivate this age group to learn such as their desire to maintain their independence. Another section of the poster listed tips on teaching older adults such as establishing rapport and making sure lighting is adequate for reading.
• Review resources and policies with staff.
One year before the Joint Commission survey, the education department at the University of Wisconsin created a patient and family education manual for all units and clinics. "It had all the pertinent information related to patient teaching such as resources that could be ordered through our internal systems, books and videos available in the learning center, and patient policies," says Engelke. There also was a section in the back where unit staff could collect materials pertinent to their clinical setting.
Preparation is key to a successful interview
• Prepare patient education committee/team for interview with surveyor.
To prepare members of the patient and family education committee for the interview with the surveyor, Engelke created a calendar of accomplishments over the past three years. It focused on how the program had grown and changed since the previous survey. "We got together ahead of time to talk about programs and areas we wanted to emphasize. One of the things we tried to do was know across the board how one program worked. For example, pharmacy would not only know the pharmacy component but also the other discipline’s component. The overall message was that we have a plan that crosses settings and disciplines," says Engelke.
• Work with administration to present patient education in the best light during the survey.
The patient education team at Union Hospital was surveyed on the third day of a four-day survey. O’Conner Finch requested the third day so the surveyors would have already completed the document review and had a chance to visit the various patient care units. "I wanted the surveyors to have a chance to see what it was we did. Also, we could get a better feel for what they were looking for," she explains.
At the end of the week, the patient education team at the University of Wisconsin invited the nurse reviewer to the learning center for a presentation. The various disciplines from the committee explained how they used the learning center to teach patients and family members. Also, staff from the education department showed videos they had produced and demonstrated computer programs used in the learning center. "It was a way to put together the whole package and show we have a strong interest in patient and family education, and we have a plan that is well integrated," says Engelke.
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