Preparing for Survey Readiness
Tips and Tools for a Successful Accreditation Survey
January 24, 2014
Message From the President
The Joint Commission - Q & A’s
We can expect an unannounced survey visit
from The Joint Commission at any time. Our
success will require the cooperation and
support of the entire staff and depends also
on everyone’s familiarity with TJC requirements in their particular area. We will be
sending out regular communications to help
each of us prepare to demonstrate our
competence and our commitment to excellence in all we do.
How will we be surveyed?
Follow the footsteps!
The Joint Commission’s on-site survey process uses
tracer methodology. Surveyors select a patient and
follow the path the patient has taken throughout their
hospital stay, observing practices, documentation and the
environment, as well as interviewing staff and patients!
Surveyors will ask questions about the care each patient
received and the steps taken to ensure that it was safe
and of high quality.
The Joint Commission is an organization that
measures hospital performance. Achieving
accreditation means that the hospital has met
or exceeds The Joint Commission standards.
How will I know the Joint Commission is conducting an unannounced survey?
Upon their arrival, we will open the Command Center
and send out a Communicator message. The survey will
last 5 days and your supervisor will keep you informed of
survey progress.
Accreditation is a nationwide seal of approval
that indicates a hospital meets high performance standards. Without accreditation our
hospital will lose its professional standing and
community image. It will also affect financial reimbursement for services provided
to patients and, most important, would not
reflect our dedication to providing top-quality patient care. In preparation for TJC’s
unannounced visit, rounding will be organized
every day. A mock survey is scheduled for
January 29, 30 and 31.
I am counting on each of you to be ready.
James Gonzalez, MPH, FACHE
President and CEO
Mock Survey
January 29, 30 and 31
What is my role in the survey?
You and every hospital employee at every level are very
much responsible for upholding the hospital’s mission and
providing excellent patient care. Joint Commission
surveyors will speak with you about your contribution to
the hospital’s overall goals and about your individual job.
What should I do if a surveyor asks me a question?
• Listen and stay calm.
• Think carefully before answering a question.
• Only answer the question asked by the surveyor. You do
not need to elaborate.
• If you don’t understand a question, ask for clarification.
• Whenever possible, mention our practices and
procedures that support your answers.
• Show enthusiasm and interest!
• Show off your successes and the things you know and
do well.
• Exhibit pride in your department.
Who is in charge of survey preparation in my area?
Your department director or manager is responsible
for the survey readiness of your area, in coordination
with the University Hospital Leadership Team and the
Regulatory Readiness Team. However,YOU are also
responsible for your own participation and preparedness.
Who sees the results of our survey?
Anyone who wants to. The results are made public and
available on the Internet. Our competitors, managed
care companies, referring physicians and – most importantly – our patients and their families will be able to
read the details of our performance.
Emergency Codes
Non-Medical Emergencies: 222
Medical Emergencies: 111
“Code Red + Location” - Fire
- All floors must clear the hallways and close all doors.
Remember...
R-A-C-E (fire instructions)
Rescue - Alarm - Contain - Extinguish
P - A - S - S (for fire extinguishers)
(Pull - Aim - Squeeze - Sweep
“Code Red All Clear” - Fire alarm has been cleared. - Resume activities.
“CodeTriage in the Command Post” - Internal Disaster
- Return to work area. Do not use phones.
- Implement department/unit responsibilities.
2014 Hospital National Patient Safety Goals
The purpose of the National Patient Safety Goals is to
improve patient safety. The goals focus on problems in
health care safety and how to avoid them.
Identify Patients Correctly
Use at least two ways to identify patients. For example,
use the patient’s name and medical record number. This
is done to ensure that each patient gets the correct
medicine and treatment. It also confirms that the correct
patient gets the correct blood when they get a blood transfusion.
Improve Staff Communications
Improve the effectiveness of communication among caregivers (“read back”, timely report of critical values, handoff communication).
Use Medications Safely
Label all medications before procedures. Reduce the
possibility of harm for patients on anticoagulation therapy.
Maintain and communicate accurate patient medication
information (Medication Reconciliation).
Use Alarms Safely
Make improvements to ensure that alarms on medical
equipment are heard and responded to on time.
“Code Triage in the ED” - External Disaster
- Do not release information to the media.
Prevent Infection
Be vigilant about hand-washing protocol. Use the “proven
guidelines” to prevent infection (difficult to treat infections, blood from central lines, after surgery and urinary
tract infections caused by catheters).
“Code Triage All Clear” - Disaster has ended.
- Resume activities.
Identify Patient Safety Risks
Learn which patients are most likely to try and commit suicide.
“Code Amber” - Infant/child abduction
- Be observant of people.
- Notify Public Safety at 222 if you see anything suspicious.
Prevent Mistakes in Surgery
Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body.
Mark the correct place on the patient’s body where the
surgery is to be done. Pause before the surgery to make
sure that a mistake is not being made. (Take a “time out”).
“Code Blue + Location” - Cardiac arrest
“Dr. Band-Aid + Location” - Staff and visitor
accidents/emergencies
OUR MISSION
To improve the quality of life for all those we touch
through excellence in patient care, education, research
and community service.
OUR VISION
To create the best possible environment for our
patients to heal, our physicians to practice and our
employees to work.
To learn more about the National Patient Safety Goals,
contact Aaron Weinberg, Patient Safety Department at
2-6373 or by email at: weinbeam@uhnj.org
This article, created for the staff, contains a reader-friendly version of the
2014 National Patient Goals.The official language of the goals can be
found at www.jointcommission.org
Working together, we can have a successful survey!