Preparing your staff for JCAHO

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Preparing your staff for JCAHO surveys is obviously necessary, but how can you best utilize your resources?

1 Tracers
2 Staff education
3 Have appropriate information at your fingertips
4 Related links

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Tracers

To receive a positive survey outcome, nearly everyone agrees that the most important preparation tool is to do Tracers, evaluate the results, and have a solid follow-up plan.
Conduct tracers on all the clinical units, all shifts to ensure that all staff is involved.
Numbers of Tracers: 31-bed hospital did 1 tracer per week.
Surveyors are very interested in how units transfer information
Examples of questions for medical staff include patient identification, site marking, communication of results throughout hospital, addressing PSGs.

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Staff education

Merrimack Hospital used the following tools:

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.)

At Aurora Sinai in Milwaukee, they really focused on the fun:Using the philosophy that if it's fun, it will help the learning process, they had the following learning tools:

The JCAHO Jingle (a video set to music showing various standards in practice.) Staroszczyk said "People seemed to enjoy that. They got to see people within their department and very often we heard people humming the tune as they were going down the hallways."
JCAHO Bingo that the staff can complete with rewards of gift certificates.
JCAHO Jam, their online JCAHO education tool.
JCAHO question of the week - managers discuss and post in their own department, and since it’s just one question it’s easy enough to quickly review.

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Have appropriate information at your fingertips

Prepared compilations with essential documents such as the organizational chart, plans for provision of care, licensure, the FMEA, staffing effectiveness, governing board, updated statement of conditions, disaster drill critiques. All leadership should know where these documents are.
At Merrimac hospital, the following documents were requested 15 minutes after surveyor arrived: Documents requested included: The surgical schedule, a census with diagnoses, discharges from the previous three days, the number of incomplete records, medical exec minutes.

Advice: If you spend the first hours trying to scramble and locate necessary documents, you will take an emotional hit that will be noticeable by surveyors and uncomfortable.

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