2009 MAGNET™ PROFILES - American Nurse Today

MAGNET PROFILES
Mission: Achieve continual
readiness for Joint Commission
surveys
An impossible goal? Perhaps not, if you follow the author’s
“E” approach.
By Barbara C. Sorbello, PhD, RN-BC, NEA-BC
It’s 8:30 A.M. Monday, and the hospital is bustling.
The operating room has a heavy schedule. Six emergency-department
patients have been admitted and
await open beds. All of a sudden, you hear “Code J” announced
over the PA system—and the nightmare begins.
The nurse manager on 2-North starts barking orders
to her staff. “Peter, clear the hallways and hide the
Christmas decorations in the storage room. Julie, make
sure our I.V. sites and irrigation sets are dated. Cathy,
check the charts and see if all our patients have up-todate
care plans and discharge plans.”
The charge nurse scrambles to verify that the crash cart
logs and refrigerator logs have been completed. “Oh my
gosh!” she suddenly exclaims. “Who took the refrigerator
thermometer? And where did all this old food come from?”
Meanwhile, the nurse manager heads for the medication
room to check drug expiration dates. She finds
the medication cabinets unlocked and sees donuts and
spilled coffee on the counter. Taking a deep breath to
calm herself, she opens the cupboard under the sink.
There she spots unit supplies, a box of cookies, and
staff members’ purses. No amount of deep breathing
can prevent her from losing her cool now!
Most of you can relate to this tale of a surprise
Joint Commission (JC) visit. It could happen on
any nursing unit on any given day. Meeting the
myriad standards and regulations established for
healthcare facilities by federal, state, and local
agencies can be challenging enough. Keeping staff
members in continual readiness for an unannounced
survey may seem nearly impossible.
Yet being in a continual state of readiness diminishes
the stress of last-minute preparations. This article
describes how nurse leaders can make sure
their staffs are perpetually prepared—and confident—for
surprise surveys.
JC’s survey approach
In 2004, the JC rolled out a new survey approach:
Their surveyors now spend more time reviewing patient-care
activities, processes, and outcomes by using
“tracer” methods and talking with staff members involved
in direct patient care. Tracer surveyors trace
the care processes patients experience during the continuum
of their hospital stays and discuss standards
with the care providers closest to the patient situation.
In 2006, JC began its unannounced survey
process, in which facilities don’t have the luxury of
preparing for surveys. Long gone are the days
when JC surveyors sat in a hospital’s conference
room all day reviewing manuals, committee minutes,
and closed patient records. Now they spend
less time on document review and more time discussing
effective care with clinicians.
Many healthcare organizations have created
teams linked to each JC standard of care. The teams
conduct gap analysis and develop performance improvement
plans for organizational readiness related
to the assigned standard. This strategy promotes a
systems-oriented approach to process improvement
and quality outcomes. Unit leaders and staff members
are responsible for implementing the teams’ recommendations
and conducting unit-based initiatives
to ensure high-quality care at the unit level.
Developing a culture of readiness
Continual quality improvement is a way of being, not
just a periodic activity. If employees merely try to get
through a survey using scripted responses, they may
perceive that the survey and their participation in it
have little value to themselves or their patients—an attitude
not conducive to feeling engaged in the process.
Instead, nurse leaders and the shared governance
committee of the nursing unit must set standards
for, and promote conditions that foster, a culture
of safety, quality, and readiness. The focus
needs to shift from merely doing what’s needed to
meet requirements, to ensuring continual performance
and process improvement.
Using the “E” approach
To achieve a culture of continual readiness for sur-
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62 American Nurse Today Volume 4, Number 8