Did you know that PPMC undergoes approximately 50 accreditation and regulatory surveys each year to verify we are delivering the safest possible care? Susan Chodoff, MBA, and Janice Gasho Brennan, RN, MSN, MSOM, CPHQ, of the Regulatory Affairs and Accreditation Matters team work hard to ensure all staff across Presby’s inpatient and ambulatory settings maintain patient- and family-centered environments. With extensive ground to cover, Chodoff, the director, and Gasho Brennan, coordinator, regularly collaborate with hospital leaders and committees to encourage ongoing education and provide resources clarifying guidelines for care environments, medication management, information management, infection prevention and control, and other topics related to care delivery and general safety.
This year, PPMC will be hosting surveyors from The Joint Commission for an unannounced, four-day visit. The team shares what staff can do to stay survey ready and the importance of keeping a quality and safety focused mindset all year round.
Q: What does survey readiness look like for your team?
SC: We don’t want compliance or survey preparedness to be viewed as “extra” work. Doing what we need to do every day for every patient is the best way to demonstrate our readiness; if we stay focused on the next patient and their experience and not just on the next survey, we’ll always be ready. Continuous readiness activities like patient and environmental rounding are already part of our daily work. Committees and workgroups also continue to review standards against the hospital’s policies and procedures, and there are ongoing simulations, drills, and audits, which help staff stay prepared for a survey that could be 10 minutes from now.
Q: What strategies do you employ to ensure every department and unit is on the same page?
JGB: We work hard to meet staff where they are, offer feedback about opportunities for improvement, and provide resources that make them feel knowledgeable and empowered to tackle process improvements. We also perform mock surveys so staff can identify and reduce risks, address gaps in care, and increase their comfort level with the process, and we hold “boot camps” with unit leadership and available staff. Teams can also help by reviewing available huddle sheets and participating in our environmental rounds, tracers, and audits. We really want to engage everyone and strive toward a common goal.
Q: Are there any tips you recommend staff keep in mind as we enter survey season?
SC: It all comes down to asking questions, being knowledgeable of work processes and procedures, and paying attention to the survey readiness efforts that are happening in every area of the hospital. How can you make your environment safer for patients and their families? Are you aware of what your department is measuring and the role you can play in improving your own care or services? Are you performing hand hygiene? Documenting care effectively? Documenting incidents in Safety Net? Staying up-to-date on requirements like your PPD and mandatory education modules? All of these areas are important to address. (We’ve also been sharing some tips in the PPMC Need to Know email, so stay tuned for more!) If you have concerns, it’s also important to elevate them to your manager or supervisor so issues can be identified and can become opportunities for learning and change. Everyone contributes to our culture of patient safety and plays a vital role in providing our patients with the best possible care. After all, that’s what the surveyors are here to see.