Multiple mock surveys are the key to Maryland agency’s JCAHO success
Agency receives two accreditations with commendation
If you check the home health agency list on the Web site for the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO), you’ll quickly see that very few agencies receive the much-coveted "accreditation with commendation" designation.
Even fewer sustain such honors for two consecutive surveys. This is because such an accreditation achievement is only slightly less difficult to achieve than a perfect 10 on the parallel bars at the Olympics. Joint Commission surveyors go into an agency looking for mistakes, tiny slip-ups, little lapses of duty and knowledge, and most of the time they find what they’re looking for.
But not so with Adventist Home Health Services in Silver Spring, MD. The home health organization, which has five offices in the Maryland, Washington, DC, and northern Virginia area, has earned accreditation with commendation in its two last surveys.
Follow the survey guide
There was no magic to the agency’s achievement: It was plain hard and smart work, says Carolyn Stevenson, RN, BSN, assistant director of clinical services for Rockville, MD-based Adventist HealthCare Alternate Care Services, which helped the home care agency prepare for its surveys. The Adventist services organization, which also consults with other home care agencies, and the Adventist home care agency are owned by Adventist Health Care in Rockville.
Stevenson, who helped the Adventist staff prepare for the surveys, offers this guide to survey success:
1. Prepare continuously.
Don’t wait until the last minute or the last year to begin preparing, Stevenson says. Adventist started survey preparation a full two years before the actual survey.
First, the company held a mock Joint Commission survey, following exactly the same survey manual that a real surveyor would follow. The Joint Commission sells its survey package, complete with computer software and print-out reports. This can be invaluable, Stevenson says.
The mock survey was conducted by two registered nurses from a consulting company. Since the surveyors were not employees of the home care agency, it ensured that the mock surveyors would be objective and the staff would take it seriously.
"The mock survey lasted a whole week, and the nurses did everything just like a Joint Commission surveyor," Stevenson says. "It’s only beneficial if it’s conducted just like a surveyor would do it."
The staff did take the mock surveyors’ report seriously. They listened to the instructions and followed up on the problems the mock surveyors noted in the report.
"There’s no sense paying someone to do a mock survey unless you listen to the recommendations laid down by the experts," Stevenson says.
2. Give staff Joint Commission areas to cover.
About 18 months before the Joint Commission survey, the agency formed a Joint Commission oversight committee of about 12 members.
Each member of the multidisciplinary committee was assigned one or more chapters from the JCAHO manual. The committee members could enlist help from other employees to go over the agency’s own policies and procedures to make sure they matched with what the Joint Commission said. For example, a member might ask for help from the agency’s clinical records department to work on the information management section.
"Staff went through each of the standards within the chapters and made sure that our agency was meeting the requirements of that standard; if it was found we were not, a plan would have to be put into place to make the necessary changes," Stevenson explains.
This job took about six months. Agency management gave the committee a fairly loose rein in making small changes. But if a change required administrative support or additional funding, the committee could make a recommendation to the operations committee for approval. Then the operations committee would make recommendations to the professional advisory committee and ultimately meet board approval.
"The oversight committee was given the authority to do what they needed to do within some boundaries," Stevenson says.
Since the area of infection control and safety is such an important part of a Joint Commission survey, the agency also had the safety committee perform a mini-mock survey of their own. Safety committee members made additional recommendations based on their findings.
3. Then repeat the mock survey.
One year after the first mock survey, and a year before the actual survey date, the agency held a second mock survey. This time the Adventist consulting arm of the health care organization conducted the survey.
The second survey confirms that the staff have improved the problems found in the first survey. It’s also a second dress rehearsal for the real thing. But since it is conducted a full 12 months before the actual Joint Commission visit, it gives the agency time to clean up any last-minute issues or problems.
Adventist’s mock survey found a problem with the timeliness of doctors’ orders. In Maryland, home care agencies must have the orders signed, returned, and in the report within 28 days — two days shorter than what the Joint Commission requires.
"This an area that’s a problem for every agency, and the Joint Commission requires 100% compliance," Stevenson says.
The mock survey also found a problem with how some staff followed wound care orders. "Some nurses wanted to document it and do it slightly differently from what the original order said," she recalls. "But these must be followed exactly."
The agency tackled these projects during the year before the survey.
4. Educate, reinforce, educate staff.
Managers eschewed the boring lecture-format inservices and instead held Joint Commission "Jeopardy" games during staff meetings.
"You have to do education in fun ways," Stevenson says.
Managers also published a monthly newsletter for employees, Compass, which included Joint Commission information updates, cartoons, tips, policy highlights, and notes on changes the agency was making in policy and procedure. (See newsletter, inserted in this issue.)
The newsletter also included word games, scrambled word games, and crossword puzzles. The first person to call in the correct answers would win "Joint Commission bucks," which could be exchanged for prizes.
"The whole slogan for the Joint Commission preparation was Mission Possible,’" Stevenson says: "We tried to make it fun."
The agency also displayed bulletin boards in its five offices. "Each bulletin board had a specific topic that was identified when we did the mock surveys," Stevenson says. For example, the bulletin boards featured information on infection control, case coordination, and discharge planning.
A last educational step involved chart reviews. Management teams conducted these as a way of ensuring that employees had corrected areas identified as problems. If they found problems, they’d give staff feedback on how to correct the errors.
Finally, as the survey time approached, the agency made sure the office looked organized and that everything was neat and tidy.
"You must present a professional atmosphere for the surveyors," Stevenson says. "Make sure everyone is wearing their name tags and that everyone is aware what our mission is."
[Editor’s note: For more information about Adventist HealthCare Alternate Care Services’ Joint Commission mock surveys and preparation, contact Ann Kirwan at (301) 315-3570; fax: (301) 315-3019; or e-mail at [email protected].]
Source
• Carolyn Stevenson, RN, BSN, Assistant Director of Clinical Services, Adventist HealthCare Alternate Care Services, 1801 Research Blvd., Suite 101, Rockville, MD 20850. Telephone: (301) 315-3570.
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