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In This Issue:
Janet Barnes and Gail Morrissey show Jeremy Stephens, medical assistant, where to look for fire equipment inspection information.
Staff at the Thoracic Surgery Ambulatory Center are always ready for every patient. That’s what the BWH Readiness Team found last week after visiting the center as part of the hospital’s preparation for the unannounced Joint Commission accreditation survey, which can take place any time between now and May 2010.
“The preparation of the staff was superb, and the way they handled and answered our questions was remarkable,” said Gail Morrissey, BWH’s director of Clinical Compliance and member of the Readiness Team.
During the center’s practice survey, Morrissey and Janet Barnes, JD, RN, executive director for Clinical Compliance and Risk Management, played surveyors and examined equipment, browsed through drawers and cabinets and quizzed staff about their responsibilities—just as The Joint Commission surveyors will do to assess compliance.
Kimberly Bilal, a surgical coordinator team leader, was one of the center’s survey stars who provided details on her role in the center as well as recent quality improvement initiatives.
“Without any notice at all, Kimberly was able to pull together information, answer our questions and show us how the center complies with organizational policies,” said Morrissey.
Also during the visit, KC Zahner, operations supervisor, led Morrissey and Barnes through the center and spoke of its accomplishments and protocols.
Morrissey and Barnes gave the staff tips on preparing for The Joint Commission survey, including:
•Examine medical supplies for expiration dates.
•Watch for clutter in hallways and other high traffic areas.
•Check fire extinguisher and make sure inspections are current.
•Understand the policies and procedures pertaining to your jobs.
The most important tip, however, is to remember to remain calm during a surveyor’s interview, said Barnes.
“If you don’t understand the question, ask the surveyor to repeat it or explain. Don’t guess if you don’t know the answer. Tell the surveyor whom you would contact to get the answer or reference a specific manual,” said Barnes.
During the hospital’s actual accreditation survey, The Joint Commission will use a patient tracer methodology, selecting patient records and tracing their care from admission to discharge. Surveyors will question many staff involved in the care of these patients. Surveyors also will trace patients of BWH ambulatory sites at the hospital and throughout the distributed campus.
Learn more online at:
www.bwhpikenotes.org/Employee_Resources/Compliance/Continual_Readiness/