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Building awareness into the survey prep process


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Educating staff members in every department about the National Patient Safety Goals allows for greater involvement and success when preparing for a survey. And Ruth Rankin plans to build hospitalwide awareness following her facility’s recent survey.

“You can’t depend on one person,” says Rankin, director of risk and quality management at Sarah Bush Lincoln Health System (SBLHS) in Mattoon, IL. “If you have the right backups in place, the survey should always go smooth, regardless of who may be out that day—first string, second string, any combination of people should allow for a smooth survey.”

Educate staff members about what to expect during a survey so that they’re prepared for an unannounced survey year-round.

Preparing for the survey

SBLHS, a 1,100-bed rural community hospital, used tracer methodology to prepare for the survey.

“As soon as the survey began and we got our first tracer assignments from the team, we put together a grid for the entire management team showing surveyor activities for the week along with staff participation assignments so they could plan to cover each tracer activity,” says Rankin.

This grid provides a cross-section view of each day so that “everyone in the organization knew what was going on in each tracer area, since separate surveyors had separate tracks that occurred simultaneously,” says Rankin. “Sometimes, a key staff person had to decide which meeting to attend if they would normally be included in sessions that were now happening at the same time and make alternate staff assignments for the other tracer tracks each day.”

Rankin says this allowed staff members to plan who to meet with in advance of sessions and to reflect on what they might want to change for the next day, or even the next survey.

Mock tracers were also helpful in preparing for The Joint Commission’s visit.

“I believe it makes sense to follow a patient through many branches of the system,” says Rankin.

An educational emphasis on mock tracers for all system leaders and staff members allows personnel to stay current with National Patient Safety Goals.

“We also stayed up to date in our departments with using various programs, newsletters, and other educational material,” says Rankin.

Anticipating survey results

When the surveyors arrived in November 2007, staff members knew what to expect.

“We quickly outlined our meeting schedule to fit within the survey days,” says Rankin. SBLHS’ survey team was able to obtain some basic information about the surveyors and their expectations.

“It was helpful to know the background of the surveyors,” she says.

Meeting with the surveyors during the survey helped staff members understand their perspective, which, in turn, helped them better prepare for future surveys.

After complying with the surveyors’ standard requests for information and documentation, Rankin quickly assembled the management team to assume the responsibilities it had been assigned in advance of the survey.

The team’s preestablished communications practices ensured that the survey process was successful.

“We made sure to use a lot of e-mail hospitalwide while the survey was in process,” says Rankin.

This enabled staff members to receive frequent updates and feedback from the department.

Rankin says good communication kept people comfortable and motivated. ”Staff understanding and involvement was key to meeting standards,” she says.

Making a single action plan that entailed how staff members were going to stay on top of specific issues addressed in the survey was a challenge in preparing the final action plan. Being able to put together an action plan even more quickly will be a focus for Rankin in preparation for the next survey. The surveyors applauded the hospital’s electronic medical record system, which has proven to be very successful in its organization.

“It’s a positive experience to pull up requested data and files within seconds for surveyors,” says Rankin.

As an advocate for hospitalwide involvement, Rankin has a variety of leaders available to be escorts during a survey and demonstrate perpetual readiness for standards and chapters.

“We also want to focus on this in the future, involving staff to be leaders in many areas,” she says.

Moving forward

Rankin says that in the future, she wants to cross-train all staff leaders in the organization. “We need generalists that are specialized in many areas, and we need people to feel comfortable helping with any part of the equation,” she says.

Since the November 2007 survey, Rankin has worked to align plans, policies, and protocols for the system’s hospice, home health, and off-site physician practice locations with those of the main campus. She has found opportunities to blend the programs and protocols in a way that has strengthened the health system as a whole. With this mind-set, Rankin says you’ll avoid RFIs.

“Meeting and regularly sharing information and gaining insight from all departments in the system can streamline the process of perpetual readiness immensely and more likely result in a great survey,” says Rankin.