Commended hospital shares its success secrets
Accreditation is part of this Princeton facility’s culture
The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, awarded the Medical Center at Princeton (MCP) in Princeton, NJ, 98 points and accreditation with commendation after its last survey — an achievement only 15% of hospitals can claim. Hospital Peer Review asked Pat Lamb, vice president, and Diana Constable, director of QI, medical records, and UR, what they did to make that happen.
"Senior management made achievement of commendation a priority for all levels of the institution," says Lamb. "We set our goal a full two years before our survey in March." MCP’s score three years ago was 95 with one Type 1. Not bad, but management knew the facility could do better. Lamb and Constable set out to implement a stringent program to overcome obstacles and achieve their goal of commendation.
First, they revised the facility’s QI plan and program. They put into place a committee to set up an internal audit and develop a process that would reveal those areas where improvement was needed. The committee came up with about 50 indicators that needed improvement or monitoring to ensure compliance.
Next, they identified a team facilitator for each chapter in the Joint Commission’s Comprehensive Accreditation Manual for Hospitals. One appropriate person was assigned the section on assessment, another took care and treatment, another took performance improvement, and so on. For example, the director of pharmacy took charge of the patient care chapter; the infection control coordinator took charge of surveillance, prevention, and control of infection; and responsibility for the chapter on management of information was assumed by the director of information systems, the director of education, and Constable.
Lamb explains, "We handed out the standards to each of fifteen individuals and said, Your homework is to come back and tell us, by individual standard, if we are in compliance. If we’re not in compliance, you need to tell us what you’re going to do about it, when it will be done, and how you’ll get it done.’ We saw this as the only way to see where we stood and get our job done." The survey preparation group met monthly or more often, and at those meetings each team facilitator gave progress reports on where they stood and how close they were to needed improvements. They were held responsible for ensuring compliance with all the standards within their chapters. If the facility was noncompliant on a standard, the facilitator reported on action taken to ensure compliance.
"We worked very hard on QI and developed quality cubes’ for each unit," says Lamb. Patient care functions are listed along the horizontal axis, and dimensions of performance are listed on the vertical axis. "The cubes showed us what we were measuring and what we were trying to improve. It gave us an opportunity to step back and ask, How am I trying to improve organizational performance?"
Lamb and Constable spent a lot of time educating the medical staff and employees. "We taught them about the Joint Commission process and about our QI priorities," Lamb says. They went over the processes they were measuring and QI methodology — plan, do, check, act — and reviewed them with the staff on a continuous basis.
Handbook helps employees prepare
Part of their education focus was to create a 24-page handbook for every staff-level employee. The handbook focused on the 10 most common recommendations as reported by the Joint Commission: credentialing; special treatment procedures; patient-specific data; assessing competence; medication use; organization bylaws, rules, and regulations; initial assessment; implementation; design; and planning and providing care. The handbook contains the mission of the institution and commonly asked questions that the authors expect a surveyor to ask staff, such as:
• "How often do you have unit/department meetings?" (Answer: Each month. If you can’t attend, review the minutes of the meeting.)
• "If you have an ethical, cultural, or religious concern regarding the care of a patient, what would you do?" (Answer: Communicate the concern to your supervisor. The supervisor, along with others in authority, will make a determination to excuse you from participating in that particular aspect of treatment or care of the patient. Under no circumstances can the care of the patient be compromised.)
• "How do you operate a fire extinguisher? (Answer: Remember PASS: Pull the pin, Aim nozzle at base of flame, Squeeze the handle, Sweep stream back and forth across base.) (See representative pages from the handbook, pp. 23-24.)
MCP conducted several mock surveys. Each facilitator became a part of a group that surveyed a particular part of the hospital, just as though they were Joint Commission surveyors.
"We also hired a consulting firm to do a mock survey for us," says Lamb. "With its help, we found that we had the right processes in place, and probably would have done well anyway, but having the firm there gave us a focus and made us take it seriously." Lamb says the consulting firm wasn’t very helpful in suggesting practical ways of implementing solutions. "That was a shortcoming, but we were able to come up with a practical solution ourselves. They’re just not in the trenches," she says.
JCAHO appreciates interdisciplinary process
Hospital Peer Review asked Constable what she thinks most impressed the Joint Commission. "The fact that the organization is truly interdisciplinary," she responded. "When the Joint Commission went to the units and interviewed staff, all members of the care team were able to speak to all the care being provided." For example, the nutritionist was fully cognizant of the treatments the nurses were providing. The nurses were familiar with what the therapists were doing.
"They were also able to speak about the QI initiatives," says Constable. The handbook the team created forced all staff to educate themselves about QI activities in the hospital and about specific initiatives that had taken place in their areas. "No member of the staff didn’t know what the Joint Commission is about," she notes. Constable says the interdisciplinary process is effective, and that impressed the Joint Commission.
"A lot of time goes into this survey preparation," says Lamb. "We look at issues sideways, backwards, and upside down to try to come up with solutions that are not only effective, but don’t take up a lot of our staff time. Getting ready for survey is the best team-building process I know.
"Our goal is to make Joint Commission accreditation a part of our culture, not just to pass the test," she continues. "We try to embrace the culture of the standards rather than merely pass the survey. As a surveyor said to me, The survey process is Management 101. It gives you the framework to succeed as an organization and to improve your overall performance as an institution.’"
"We were very impressed with our surveyors," says Lamb. "They were extremely competent. They knew the standards and knew exactly what questions to ask. I think they are very well-trained." She says, however, that they were not as consultative or educational as she would have wanted.
She says she would love to see more sharing from the surveyors. "We’re all in this for the same goal — improving patient care and outcomes — and I wish we could all share how we get there," says Lamb. "These surveyors have been all over the country, and I’d like to see them share what they’ve learned about the best practices out there. If an institution does something better, I want to know what that is. I want the best practice in my hospital. That would be helpful."
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