Joint Commission Survey Readiness: Always Ready for Every Patient
When Joint Commission surveyors walk into BWH for the hospital’s next unannounced survey, which can take place anytime between now and May of 2010, they will find that the Department of Nursing’s commitment to patients and families to provide excellent nursing care with the best staff in the safest environment is closely aligned with Joint Commission standards.
“As part of the Nursing Department’s committee structure, last year’s launch of the Quality, Safety and Care Improvement Committee supports the staff nurse’s ability to drive care improvement to the bedside,” said Mary Antonelli, MPH, RN, quality manager for Nursing Surgical Services and a committee co-chair.
“The focus on a standard nursing department approach to improving hand hygiene compliance rates, hand-off communications and preventing patient falls provides the framework for nurses throughout BWH,” said Stephanie Capello, RN, committee co-chair. The committee’s work is aligned with the Joint Commission’s 2009 National Safety Patient Goals.
“We emphasize assessing patients’ fall risk and communicating this risk through the use of the plan of care and at hand off to all members of the patient’s care team,” Antonelli said.
Clinical nurses also are engaged actively in efforts to better document and reduce the use of patient restraints. Staff in the ICUs are committed to reducing restraint use to 15 percent this year. This goal has already been accomplished by the 9CD staff by implementing a few changes in practice. Another focus is on improving documentation when monitoring patients who are in restraints for safety while continually reassessing to remove the restraints as soon as possible.
Joint Commission surveyors may ask staff about use of restraints and other aspects of care as they work their way throughout the hospital using the tracer methodology. Surveyors trace a patient’s care through their medical records, touching base with staff in all areas of the hospital who may have been involved in that patient’s care. This could take a surveyor through an ambulatory practice to inpatient units and everywhere in between.
Diane Lancaster, PhD, RN, Nursing’s director of Quality Measurement and Improvement, said that staff should feel confident going into the survey. “Overall, if we continue to focus on the National Patient Safety Goals and documenting the outstanding care our staff provide every day to every patient, we will make a very positive impression on our Joint Commission survey team,” she said.
Always Ready for Every Patient
Top Ten Tips for Survey Readiness
- Wear your ID badge at all times above the waist.
- Know your role in patient safety and the NPSGs.
- Know the fire and disaster procedures on your unit.
- Know how to access Material Safety Data Sheets.
- Exercise proper hand washing and fingernail hygiene.
- Be familiar with policies and procedures pertinent to work you do and where to find them.
- Review your documentation around assessment, reassessment and plan of care.
- Label all medications and IV solutions.
- Know the hospital restraint policy.
- Know three competencies necessary to do your job.