A medium hospital's experiences with JCAHO

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On March 9, 2006, JCAHO had a conference call regarding unannounced surveys and here are some highlights from a medium hospital's experiences with JCAHO. The complete transcript from this discussion can be read on JCAHO's website. JCAHO asked representatives from Merrimack Valley Hospital, a 140-bed facility in Haverhill, MA, to speak about their experiences. Gloria Swanbon, Director of Quality Management and Patient Advocacy, was the speaker.

1 How they prepared
2 Experiences with survey
3 Advice
4 Related links

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How they prepared

Goal was to promote a culture of readiness and increase the confidence of staff.
Conducted tracers on all the clinical units, all shifts to ensure that most of the staff would be involved.
Posters and monitoring reinforced the PSGs.
They put up a JCAHO Jeopardy Board throughout the hospital so as staff walked by they could stop and play JCAHO Jeopardy.
They have a screen saver on everyone’s computer with some of the safety goals that they want to emphasize, consisting of three rotating pages. (Their screensaver had the “do not use” abbreviations list, one has universal protocol and the third one has a hand hygiene reminder.)

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Experiences with survey

They had three surveyors; a nurse, a physician, and a preceptee who was in training (JCAHO asked permission to have the trainee attend).
They presented at the front desk and after the Director of Quality Gloria Swanbon showed up, requested a planning meeting with the senior leadership in about 15 minutes and another planning meeting shortly thereafter with the other managers. Knowing how difficult it can be to reach managers at their desk first thing in the morning Ms. Swanbon had the switchboard announce that "Merrimack Valley Hospital welcomes the Joint Commission to our facility today and we hope you enjoy your stay."
Documents requested included:

The surgical schedule
A census with diagnoses
Discharges from the previous three days
The number of incomplete records
Medical exec minutes

The survey began immediately with two simultaneous tracers, and staff were highly involved with tracers and the environment of care reviews
Surveyors met with hospitalists, ED physicians, radiologists, and anesthesiologists
The majority of the time takes place at the patient care level rather than the paper level.
They were asked for few policies, those that came up in the tracers

administration of blood and confirmation/ID of patient
timing of updating care plans
physician leave policy from Med Exec minutes

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Advice

Do many tracers, involving all shifts. Tracers increase comfort levels and familiarity.
Coordinate vacations among the key players and have alternates who can step in and facilitate and coordinate the actual survey.
Having the switchboard announce that "Merrimack Valley Hospital welcomes the Joint Commission to our facility today and we hope you enjoy your stay." enabled them to notify 90% of the hospital that the survey was happening.
Gloria Swanbon says "...after the initial shock, you will find that this is less stressful."
The JCAHO Jeopardy and Screensavers were particularly effective ongoing teaching tools

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