|
The Hospital Express
What Speacial Preparations is Your Hospital Making for Unannounced JCAHO Surveys? What About Disease-Specific Care Certifications?
|
|
Sequoia Hospital By Leonard A. Valentino, M.D President Professional Staff Sequoia Hospital has instituted a protocol of "continual survey readiness" to ensure a uniform strategy with unannounced JCAHO surveys. Mock surveys are conducted throughout the hospital every month, allowing opportunities to educate staff and physicians as well as to identify areas for improvement. Staff members on all units have undergone training to be JCAHO survey "experts"—they are the eyes and ears for their peers on what the expectations might be during an actual survey. Monthly leadership meetings are conducted to review areas for improvement and to monitor action plans on an ongoing basis. Numerous individuals participate in local as well as national seminars regarding state, CMS, and JCAHO requirements. With regard to JCAHO Disease Certification Programs, key hospital personnel are working with San Mateo County on both JCAHO certification and for a community strategy for early intervention and treatment of stroke patients. Sequoia has also recently begun preparing for Inpatient Diabetes Program certification. This certification program was selected because Sequoia has been recognized as a leader in the management of hypoglycemia in the hospitalized patient.
Mills-Peninsula By Keith L. Duncan, M.D Chief of Medical Staff At Mills Peninsula Health Services we conduct weekly patient tracer rounds. A core team of environmental and clinical staff, along with a senior leader, chooses one patient care area and spends one hour reviewing the environment, medical records, and interviewing staff. The staff is now very comfortable discussing care issues and welcomes team visits. We developed a Global Audit Tool for which each clinical unit must review 14 of its patient records each month and make observations on every shift. These results are tabulated monthly and shared with all staff. Unit level results are just now being shared. Our JCAHO Champions meet monthly to discuss areas for improvement. We had to complete the Periodic Performance Evaluation (PPR) twice in one year. This has been valuable in identifying problematic areas. A yearly Mock Survey is conducted by six to eight Sutter corporate staff members and two affiliate members. The Mock Survey covers all JCAHO Standards. We receive a verbal and written report after the Mock Survey and use that for action planning. Monthly conference calls with Sutter-affiliate Regulatory Coordinators and the Sutter corporate team keep us up to date on standards changes. On the Disease-Specific Care Certif-ication front, Mills Peninsula Health Services recently underwent a Joint Commission Stroke Certification Survey for which we anticipate notification of certification in November.
Seton, Seton Coastside By Julius L. Zsigmond, M.D. President of Medical Staff
Seton Medical Center had its last announced JCAHO survey in August 2005. The preparation for the survey caused a lot of anxiety among the hospital associaAtes, even disruption of the smooth daily routine that is essential for efficient patient care. Since then, we have worked hard to maintain the standard that we achieved with the intensive campaign-like work and keep physicians and hospital staff in a state of continuous JCAHO readiness. Seton holds monthly JCAHO Readiness and Patient Safety Committee meetings in which team leaders for JCAHO chapters of standards report on our compliance level with each standard or National Patient Safety Goal. If we are below 100 percent, the action plan for getting to 100 percent is discussed and then implemented. All levels of staff are held accountable for meeting the JCAHO standards and safety goals and for auditing the compliance, either through chart review or direct observation. Seton also has independent outside consultants who perform full mock JCAHO surveys to identify areas that need improvement. Quarterly newsletters go out to staff with brief updates on JCAHO standards and National Patient Safety Goals. Annually, staff members participate in refresher courses while attending review days. They have also found games such as "JCAHO Jeopardy" and "JCAHO Feud" to be educational and fun. The hope is that, with time, JCAHO readiness will become part of our culture.
Kaiser Redwood City By James O'Donnell, M.D. Physician-in-Chief
Kaiser Permanente Redwood City has just undergone a survey by JCAHO as part of an effort to become accredited as a Primary Stroke Center. We sought the certification in large part because we are the Neuroscience Center of Excellence for Kaiser Permanente for most of Northern California. As of this writing, we have not seen the results, but we were greatly encouraged by the positive feedback we received from the surveyors. Kaiser Permanente Redwood City is one of many Kaiser Permanente facilities in Northern California, and one of many non-Kaiser Permanente facilities, to seek stroke certification. It is our intention, when JCAHO completes its next set of criteria, to seek certification as a Comprehensive Stroke Center. We spent more than two years preparing for the survey. We assembled a multi-disciplinary team to lead the medical center in the effort. Our tactics were organized into four stages. Plan the program: Prepared standardized, pre-printed physician orders, creating a multidisciplinary stroke care pathway, and drafted an education plan for hospital staff. Develop & Implement Plan: Put in place a Facility Wide Stroke Alert Protocol Policy & Procedure and stroke education for staff. Check the effectiveness: Monitored use of stroke order sets and interdisciplinary carepath, practiced Code Gray calls to test the system, and reviewed stroke outcomes data. Act to hold the gain: Ongoing monitoring of the JCAHO priority performance measures.
San Mateo County By David S. Marcus, M.D. Chief of Medical Staff At San Mateo Medical Center (SMMC), we believe our best preparation for an unannounced JCAHO survey is to be ready every day, any day. Like many hospitals, we have consciously raised the bar on quality and patient safety over the past few years. We ask our medical staff, employees, and volunteers to continually improve the quality and safety of the care they provide every day. Of course, in running a complex health care delivery organization such as SMMC, we cannot make progress and assure preparedness without putting appropriate processes and systems in place. To permeate quality and safety through everything we do, we have established many mechanisms that help push us forward: • Each department has developed a quality plan, based on JCAHO accreditation standards. We routinely monitor these plans to determine areas of strength and potential improvement. • We created a "Continuous Readiness Committee" whose charter is to ensure that all areas of San Mateo Medical Center are ready for a JCAHO survey, at any time. • We developed a Tracer Group that acts as surveyors would act during a survey, tracing a patient’s course of treatment, and asking staff questions about how they provide care. • On-going education is provided through our employee newsletter, E-Mails, staff guidebook, posters, our internal Web site, and special classes.
Kaiser S San Francisco By Michelle B. Caughey, M.D. Physician-in-Chief Being continuously ready for surveyors is truly a challenge for all hospitals. It’s a bit like staying ready to show your in-laws your closets at any time! Our approach has been to make readiness a part of our everyday culture. We’ve taken many of our traditional preparation-for-survey steps and modified them to meet today’s requirements, and we’ve invented new procedures and processes as well. Here is a sampling of how we maintain continuous readiness. • We have created workgroups with specific department managers and physicians responsible for certain areas of the Periodic Performance Review (PPR) to identify and address compliance issues on an ongoing basis. • We have set up an Accreditation, Regulatory and Licensing (AR&L) Committee, which reports quarterly to the Medical Executive Committee. • The Accreditation, Regulatory and Licensing Committee and other Medical Staff Committees review the PPR and JCAHO standards regularly and make changes to operational policies and clinical processes as needed to stay current. • Senior leadership reviews the PPR regularly. • We conduct simulations of JCAHO’s tracer methodology using tracer activities from the Department of Quality Management and share the results with managers and through the AR&L Committee.
|