Joint Commission Visit a Success
The 2007 Joint Commission survey was completed on a successful note with BWH remaining fully accredited. This is a major achievement for a complex teaching hospital like BWH. Thank you and congratulations to the nursing and support staff for helping BWH to achieve this positive result!
JCAHO standards are designed “to promote patient safety and quality of care through performance improvement.” The surveyors used the tracer methodology to evaluate compliance with the standards relating to patient care experiences, the physical environment and the leadership of the organization.
Nurses who spoke with the JCAHO surveyors were able to demonstrate that quality and safety processes are a part of their practice and important in providing their patients and families with the care that they need. Diane Lancaster, PhD, RN, director of Quality Measurement and Improvement for Nursing, said, “Because our nurses know their patients’ stories and strive to provide excellent clinical care, safety and quality processes become integrated into daily patient care and are demonstrated through such practices as effective hand-off communication, read back for critical test values, and consistent hand hygiene.”
During the five day survey, practice was compared to the intent of each Joint Commission standard and was evaluated as either compliant or not. When noncompliant, a “requirement for improvement”(RFI) was issued. BWH received 12 RFIs, five of which related to the National Patient Safety Goals (NPSGs), four to the environment of care, and one each in restraint documentation, documentation of MD reassessment of the patient’s H&P on the day of surgery and review of medications by Pharmacy in some outpatient and procedural areas. Most of these were not a surprise as they represent areas BWH has been working on. Five of the RFIs are being clarified because BWH believes what the surveyors saw did not represent usual practice. If the Joint Commission agrees with the clarifying documentation, then the RFI would be removed from the survey findings.
Action plans must be submitted for all remaining RFIs and must include a description of corrective action that is already in place, as well as measures of success and follow up evaluation methods. These action plans must be submitted to the JCAHO within 45 days post survey.
The Nursing Department continues refining a program to keep BWH in an “Ever Ready” state. The focused attention in the months before the unannounced survey taught BWH that it’s necessary to work consistently on the National Patient Safety Goals.
“Patient safety requires the entire team to stay focused on the patient and stay in partnership,” said Mairead Hickey, PhD, RN, chief nursing officer and senior vice president of Patient Care Services. “This is part of our role as nurses and so important to our ‘Ever Ready’ philosophy.”
Moving forward, BWH may be randomly selected for a one-day validation visit from the Joint Commission at any time, which means BWH must demonstrate that the action plans and follow-up measurement described in action plans have been implemented. The next full Joint Commission survey can occur anytime from 18 to 36 months after the 2007 visit.