Cover your bases on next Joint Commission survey
November 1, 1999
Cover your bases on next Joint Commission survey
How can nurse managers plan today for an accreditation site visit tomorrow? To take the stress out of your next accreditation survey, Critical Care Management asked two veteran ICU managers who recently underwent the process for their suggestions. Here’s what they had to offer:
• Orient your staff. In the past, reviewers limited their interviews to key personnel, chiefly physicians, head nurses, and administrators.
Today, they are more likely also to speak to bedside nurses, technicians, dietitians, and even the pharmacist, says Roberta Fruth, RN, PhD, vice president of nursing at Catholic Health Partners, a three-hospital system in Chicago.
Therefore, take a multidisciplinary approach to the process and prepare your entire staff through frequent meetings and training sessions that cover their areas of expertise and questions that reviewers are likely to ask them.
• Identify key areas of importance. For the ICU, areas of concern for the reviewers are likely to include data on patient acuity, monitoring, morbidity and mortality, outcomes, lengths of stay, discharge and transfer planning, and admissions criteria, says Fruth. So have your data available and presentable.
The physical plant and related features of the ICU are likely to be secondary concerns. But they should not be ruled out, especially when those questions are posed to staff members who usually aren’t required to be knowledgeable in those areas, Fruth adds. Can your nurses locate the exits in the unit?
• Keep up your documentation. Regardless of the proposed reforms, the Joint Commission isn’t likely to lighten its touch on documentation, says Susan Goran, RN, MSN, a staff development specialist at Maine Medical Center in Portland.
For the ICU, this means the medical charts, but equally includes living wills, advanced directives, and restraint policies and procedures.
"The reviewer is very likely to ask one of your nurses where in the chart the advanced directives are kept. And it’s always the one chart without it that they pluck from the batch," Goran says.
• Make certain paperwork adheres to standards. If the unit’s policies dictate that the charts’ contents be arranged in a certain fashion, make certain that all the charts reflect the policy, says Goran. And ensure that all the charts are routinely kept where the policy states they should be kept.
• Coach your staff on interviews. Giving too much information is often worse than not giving enough. In an accreditation survey, reviewers are likely to infer that the staff is reading from a prepared script.
Or worse, the additional commentary may open doors to additional questions that weren’t previously considered. So instruct your staff to keep their replies succinct, to the point, and brief, says Goran.
• Keep the staff informed. Let them know when the reviewers are expected, what their mission is, the importance of the accreditation process to the hospital and their jobs, says Goran. This will inform the staff of the importance of their performing well during the site visit, she adds.
• Eliminate extraneous policies and procedures. Six months prior to a visit, review the unit’s policies and procedures and discard what may be extraneous or can lead to problems, Goran says. And make certain the policies conform to actual practice.
The policy may state that certain patients must be turned every 15 minutes when in actuality nurses are doing so every 30 minutes.
• Plan ahead. Six months to a year is ample time to prepare. By doing so, you have that much advanced time in ensuring that all documentation and policies reflect the unit’s established standards, say Fruth.
Reviewers are known to pull charts that are a year old. By starting to plan early, those records are more likely to be in good order, she says.
• Avoid going on the defensive. Although the Joint Commission has stated it wants to avoid antagonism, providers are likely to sound defensive anyway, especially on shortcomings.
"Stay cordial and don’t try to avoid answering, but outline plans for correcting specific flaws," Fruth says.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content