CoxHealth, a three-hospital system in Springfield, MO, is currently awaiting its latest triennial survey at any moment. Fortunately, with a series of survey preparation tools and practices in place, the system's accreditation coordinator was confident in the system's ability to handle the pending survey.
Preparation and education for staff has become an evolving concept for hospitals, says Ruth Anne Moore, accreditation program manager at CoxHealth.
"There are more scoring opportunities than ever before. Eventually this will all be helpful but for now" it means putting the newest and most accurate information in the hands of the people who need it, says Moore. This means multiple presentations to leadership, department heads, and other managers.
The organization has also devised survey tips and preparation processes that occur at steady but not overwhelming intervals—weekly, biweekly, and monthly—to help keep all staff and departments prepared for the next survey.
The J-Blitz is a survey prep tool doctored to meet the specific needs of the system.
"Blitz was a quick, 'offensive' rather than defensive term to prepare for a survey," says Moore. "A cheat sheet of sorts."
The tool, a weekly checklist of preparatory tasks, had been in-house for some time, but had really become something the system relied on over the past year.
"We had it out there, but we really weren't using it until this past year, knowing that we were scheduled for a full triennial survey," says Moore.
Specific staff members use the J-Blitz—in essence a last-minute check list to prepare for surveyor arrival—every Sunday night to catch last minute details.
"We asked managers to designate someone to do this every Sunday evening—we're scheduled for a five-day survey, so surveyors are probably going to show up on a Monday morning," says Moore.
Knowing that these necessary tasks are checked off prior to every Monday morning works to alleviate fears by managers—and keep compliance with Joint Commission requirements steady.
"It gives managers a sense of comfort," says Moore. "It gives them something they can look at when they hear the welcoming page for The Joint Commission surveyors."
The tool was originally created with a list of 25 last-minute items to check on before surveyors arrive, but CoxHealth had tailored the list to suit its facilities and increased the list to 30 items.
"We've adapted it, changed things," says Moore.
Also included on the tool: Tips for talking with surveyors and added reminders on restraints standards.
"With all the recent CMS changes on restraints, and now with The Joint Commission's integration with CMS, we felt like this was a focus area," says Moore.
Departmental checklists
The J-Blitz is not the only tool CoxHealth uses to track its survey readiness. More in-depth department checklists have been created to go over questions that might arise on hot-button issues like medication management and National Patient Safety Goals.
"The Blitz is the down and dirty checklist. The department checklist is more in-depth and is divided into areas, including environmental services, security, infection control, safety, medication management, and more," says Moore. These surveys are conducted on a monthly basis.
FridayFacts
In addition to weekly and monthly checklists, CoxHealth also makes use of bi-weekly "FridayFacts," an internal newsletter-style set of tips for survey. Created by Moore's predecessor, the FridayFacts arrive in a Q-and-A format and are crafted to help staff know how to talk to surveyors. The answers are worded in a way to provide an outline for the right way to address questions from surveyors to cut down on nervousness or confusion.