ACCREDITATION TIP
Physicians and nurses must be involved
Leaders of same-day surgery programs should be involved in the design and any redesign of their facilities in order to meet the leadership standards from the Joint Commission on Accreditation of Healthcare Organizations, says Ann Kobs, sentinel event specialist for the department of standards at the Joint Commission.
"The physicians need input. The nursing staff needs input. Why? Because you’re the ones who are going to work there," Kobs says.
Managers know patients’ needs and patient flow, which are critical, she says. "It becomes a very different kind of unit that’s been designed by the collaborative caregivers than one designed by an architect who’s guessing at what you’d like," Kobs says.
Who are the leaders?
According to the Joint Commission, leaders include the chairman of the governing body, the chief of the medical staff, the CEO, the chief of nursing, the director of quality, other elected and appointed leaders in those categories, department heads, and anyone who directs patient care. "We say to all of you who are leaders that you participate in policy decisions, communicate the hospital’s vision, mission, values, priorities, and you collaborate to design services," Kobs says.
It’s particularly important for nurse leaders and top administrators to be involved in the operation and business of the program, says Marshall M. Baker, FACMPE, president of Physician Advis ory Services, a Boise, ID-based health care services firm providing transitional management and consultation to physician practices and health systems. Baker has been a surveyor for the Accred ita tion Association of Ambulatory Health Care since 1978.
For example, nurse leaders and administrators should attend meetings of the governing board when their areas of responsibility are being evaluated, discussed, or debated, he says.
"They don’t have to be at the table when the vote is taken, but they certainly should participate in the process," he says. "The governing body should govern, and managers should manage. That should be documented and demonstrated."
And don’t forget your physicians, he emph asizes. Physicians should be professionally invested in the same-day surgery program, regardless of whether they are invested financially, Baker says.
"As I walk down the hall and ask a surgeon a question, I don’t want the answer, I just come here to operate. I don’t know what’s going on,’" he says. "Leaders have a responsibility to facilitate regular attendance at their medical staff meetings by all providers who use the facility. And it must be documented." (For tips on getting your physicians to attend meetings, see Same-Day Surgery, June 1998, p. 78.)
Joint Commission leadership standards LD.2 through LD2.7 basically constitute the job description of the leader, Kobs says. "It says you need to have your department integrated with the hospital, coordinate with other departments, implement policies and procedures, recommend sufficient staff, determine the staff competence, and maintain quality control programs," she explains.
As part of ensuring you have competent, qualified staff, expect surveyors to ask to see the dollars budgeted for education, Kobs says.
Another tip: As part of quality control, quit obsessing over the temperature of the refrigerator, she advises. The bottom line is how you know if the refrigerator is the right temperature, Kobs says.
"Do you have to take it every shift? No. Do you have to check it every day? No. But you need to check it with some regularity," she says.
Consider buying a digital clock at a hardware store that will flash if the power goes out, Kobs suggests.
"How simple," she says. "Then you don’t have to worry about all the crazy checking."
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