After two years in the making, survey preparation pays off
Home care agency has a near-perfect survey
(Few organizations ever received the Joint Commission on Accreditation of Healthcare Organizations "accreditation with commendation." Starting this month, the Joint Commission will no longer offer the honor as an official decision category. The board thought the designation, introduced nine years ago this month, no longer is needed because performance reports are now readily available to the public, giving consumers detailed information on how health care organizations compare with each other. Also, the commission’s board said the "with commendation" designation placed undue pressure on senior management staff. Here’s a rare look at how two different organizations achieved the highest designation the commission had available. The designation may be gone, but the rewards of hard work and attention to detail needed to achieve it never go out of date.)
Meeting accreditation standards, whether it’s for the Community Health Accreditation Program (CHAP) of New York City or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL, has become a full-time job for many home care agencies, particularly in the months preceding their first survey.
But to the select few organizations that strive for and sometimes actually achieve a perfect survey score, it’s a full-time job all the time.
Aultman Health Foundation of Canton, OH, has a Joint Commission task force of as many as four people who work on the process year-round. The hospital’s home health agency is a part of the task force and the continuous preparation process. The hospital’s and agency’s hard work resulted in its receiving an "accreditation with commendation" designation, meaning its Joint Commission survey produced no mistakes or flaws that needed to be corrected.
Prior to its last survey, in late 1998, the hospital system spent two years preparing for the survey, holding weekly task force meetings, says Carol Zurakowski, BSN, manager of quality and infection control and utilization management for the 643-bed hospital.
"We brainstormed in big group and small meetings about what standards were changed, what our obstacles were, and what were the barriers standing in the way to proceed. Then we’d try to figure out how to break down those barriers and become compliant with the standards," she says.
Form survey task force
The hospital’s home care agency formed its own task force that divided up tasks, according to the Joint Commission standards, says Joan Pugnale, RN, infection control coordinator and quality improvement coordinator for home care for Aultman Health Care in Your Home.
"From October 1997 to October 1998, we had our own task force centered around home care, and we divided up the chapters and gave responsibilities to different managers," she says.
The home care task force included an infusion service manager, a pharmacist, the director of nursing for hospice, and the agency’s director, as well as Pugnale. "Those meetings became intense in that last year as we’d meet weekly and go over the standards."
When the home care task force first began to meet a couple of years before the survey, managers reviewed the Joint Commission standards manual. Later, they divided up the chapters and asked key employees to work on those standards either by themselves or forming their own task force. One year before the survey, they had a mock survey provided by a consultant, Pugnale says.
She and other home care managers also attended hospital survey meetings, and a hospital quality manager would come to the home care meetings every two weeks.
"That person had experience with hospitals and home health care, and she assisted us with the accreditation process, bringing a lot of support information to us," Pugnale recalls. "We would compare and look at how our interpretation of a standard was a little different from other home care agencies."
The hospital held a series of classes that managers from all departments, including home care, could attend to learn about the Joint Commission accreditation process, says Jackie Toth, RN, BA, CIC, Joint Commission coordinator for Aultman Health Foundation.
"We put together handouts to post and discuss with the staff, and we had a Joint Commission educational fair for the staff," Toth adds. "One big part of the educational process was we had a film that we’d obtained from the Greeley Co. [Marblehead, MA] on how to talk comfortably to a surveyor, and we showed that to the staff over and over."
The Joint Commission fair had stations with bright decorations, balloons, and upbeat colors. The hospital served hot dogs, chips, and sodas during mealtimes to attract employees during their lunch or dinner hours, Zurakowski says.
Each station had different games with prizes, such as hospital marketing gifts. For example, one station had a golf game on quality and infection control. Participants would be asked a question, and if they answered it right they could attempt a hole-in-one and win a prize, she adds.
Joint Commission fair included games, prizes
"Each table had a list of questions a Joint Commission surveyor might ask," Toth explains. "They were color-coded and had suggested answers."
More than 1,000 employees attended the fair over the hospital’s three shifts.
The hospital also published a newsletter that Pugnale used to distribute Joint Commission questions to the home care staff. "We had a booklet produced by the Joint Commission; it had examples of questions that a surveyor might ask field staff, nurses, home health aides, and therapy staff," Pugnale says.
Learning from mistakes
The home care agency held educational meetings in which managers asked employees those questions and had them answer as they would to a surveyor.
"In the year leading up to the survey, we held several classes so things would stay fresh in people’s minds, and that they would learn different ways to answer a survey question because there’s not always one answer, depending on what your discipline is," Pugnale says.
Their other survey strategies included sending managers to Joint Commission seminars and networking with other home care agencies to learn how their surveys went and what mistakes they made or overcame.
In the two months before the survey, the hospital and home care agency task forces met and reviewed standards at an intense pace. "We practically lived at these task force groups, helping them with preparation," Zurakowski recalls. "In the last week prior to the actual survey, we did a mock survey interview, asking questions at the home care agency as though we were surveyors."
The hospital quality managers also reviewed the home health agency’s case files, human resources files, policies and procedures, contracts, and interviewed leaders and prepared board members. Through this last effort, they identified where the agency needed to do extra preparation, she says. "That was the frosting on the cake."
• Joan Pugnale, RN, Infection Control Coordinator and Quality Improvement Coordinator for Home Care, Aultman Health Care in Your Home, 4510 Dressler Road, Canton, OH 44718. Telephone: (330) 493-3344.
• Jackie Toth, RN, BA, CIC, Joint Commission Coordinator, Aultman Health Foundation, 2600 Sixth St. S.W., Canton, OH 44710. Telephone: (330) 452-9911.
• Carol Zurakowski, BSN, Manager of Quality and Infection Control and Utilization Management, Aultman Health Foundation, 2600 Sixth St. S.W., Canton, OH 44710. Telephone: (330) 580-6402.
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