setting the stage for a successful survey. tjc extranet is checked daily key staff have job action...
TRANSCRIPT
TJC Extranet is checked daily
Key staff have job action sheets that are regularly reviewed
Key leaders and survey support staff rotate early arrival
All staff and physicians know Code TJC responsibilities
Communication plans have been tested & are solid
It’s 7:40 a.m. Are You Ready for a Survey?
Notification that TJC is onsite is when they walk into Administration
Key staff are unavailable and unaware of survey procedures
Staff are caught off guard, confused and nervous
Communication is sketchy & survey news travels slowly
Yep Nope
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Tip: A survey can be made (or not!) in the first 30 minutes – be prepared.
Have a plan - Code TJC Define expectations & responsibilities Assign tasks – in writing Prepare ahead Survey Ready Cart!!!
Ongoing education at all levels Board Medical staff Leadership Staff
Survey Readiness Process & Plan
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Survey Ready Cart Orientation to the Organization presentation Joint Commission required documents Marketing packet Local restaurants & points of interest
TIP: This cart should be well maintained, always current & immediately available
Plan for the Unannounced Survey
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Survey Readiness Guide Key Contact/Phone Numbers – Call Tree
Notification System Job Action Sheets – Key Staff Job Action Sheets – Unit Specific Readiness Checklists
Environment of Care Medical Records
Tracer Documentation Tool Survey Etiquette (staff & management) Survey Activity Guide Standards/SOAR/Related Documents
Structure, Structure, Structure
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Operator
Reception Areas
Leadership Team
Directors
Managers
Patient Care Areas
Non Patient Care Areas
Job Actions
Survey Coordinator
Surveyor Escorts
Blitz Leaders
Runners
Security Officer
ADN
Administrative Assistants
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Leadership Team Drivers
Management Coaches
Staff Star players
Survey Support
Surveyor Escorts Guides
Scribes Documenters
Runners Assistants Messengers
Blitz Leaders Staff support
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Conductor to staff – Host to Surveyors
Demonstrate leadership
Support colleagues & staff!
Manage Command Center
Assign responsibilities
Be ready – greet surveyors enthusiastically
Be honest – you know what you do – share it!
ALWAYS BE POSITIVE – others will read your body language
What’s the Survey Coordinator’s Role During a Survey?
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You’ll also need to be: Coach and Facilitator Mentor and Friend Compassionate – your colleagues will need it! Enthusiastic & confident
And … Stroke your team – acknowledge members of
the team – how they are involved Thank Everyone for their participation!
What’s the Survey Coordinators Role During a Survey?
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Role Serve as guides for assigned Surveyor Escort Surveyor on all tracer & other survey
activity Serve as liaison between Surveyor &
organization staff Develop a collegial rapport with Surveyor Report any and all concerns, potential
findings, issues, etc. to Command Center
Surveyor Escorts – What do they do?
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The Skill Set Knowledge of organizational policies &
procedures Good wayfinding abilities Ability to “read” surveyor body language Keen communication skills – document tracer
activity; share results with Command Center Good interpersonal skills A positive approach & commitment to
organization!! A SMILE!!
Surveyor Escorts: What competencies do they need?
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Specific Survey Tasks: Guide the way (know the best way to go!) Interact with Surveyor – respond to requests Serve as a friendly, reassuring presence for
staff Listen to every word; watch every look;
examine body language of Surveyor to determine concerns
Surveyor Escorts: What’s the job description?
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Engage in polite, professional conversation throughout survey process – share all the best about your organization
Report at least twice daily (lunch & end of day) to Command Center Share all findings, anything of concern (i.e.,
staff unable to answer question, challenging physician interactions, etc.)
Identify developing trends (i.e., two medication reconciliation forms not complete)
Share Surveyor biases (i.e., wanting to see care planning done in a particular way)
Surveyor Escorts: What’s the job description?
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Work collaboratively with Surveyor Escort to guide TJC Surveyors
Be the official documenter of all tracer activity
Use Tracer Documentation Tool to capture comprehensive information on EACH patient tracer. Must have: Patient label Staff names Physician names Questions asked by Surveyor Concerning responses by staff Topic areas reviewed & any concerns/findings
Scribe – What’s the job description?
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Deliver Tracer Documentation Tools to Command Center frequently - at least at lunch and end of day
Report significant concerns to Command Center immediately
Scribes – What’s the job description?
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Same skill set as Surveyor Escort The Skill Set
Knowledge of organizational policies & procedures
Good wayfinding abilities Ability to “read” surveyor body language Keen communication skills – document tracer
activity; share results with Command Center Good interpersonal skills A positive approach & commitment to your
organization!! A SMILE!!
PLUS – good attention to detail
Scribes
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Role & Survey Specific Tasks Provide support & “leg work” for Surveyor
Escorts Pull requested policies Get staff, management for tracer discussion Alert other departments of impending visit Get urgent information to Command Center
expeditiously Call in requests to Command Center
Runners – No running necessary!
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The Skill Set Ability to be “seen & not heard” Knowledge of the floor plan Access to all areas Knowledge of policy, procedure, resource
availability Understanding of survey process & TJC
standards
Runners – A special breed
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Role & Survey Specific Tasks Provide support & oversight of
unit/department staff in assuring constant state of readiness throughout survey Conduct rounds on assigned units Ensure environmental sweeps, medical record
checks, medication security, patient safety rounds are being done
Provide assistance, support and “cheerleading” to staff & unit management
Blitz Leaders – The Advance People!
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Team Owners Set the tone and provide the resources and
reassurances necessary to create a positive survey environment
Participate actively throughout survey process – be present to Surveyors
Demonstrate accomplishments & share the vision
Provide honest, frequent feedback
Leadership – Drives the Event
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Participate in survey process
Oversee “job action” responsibilities
Exude positivity & confidence
Provide support, encouragement & praise to staff
Management – Go Coach!
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Demonstrate the high quality, safe care you provide EVERY DAY!
Share all the good initiatives organization is involved in
Show your pride!
Physicians & Staff – Star Players
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Security & Reception – greet surveyors; notify Survey Coordinator/Administration
Administrative Assistants – clear conference rooms; contact Leadership; order food!
Operator – predetermined script for call notification & paging
Clinical Managers – assignments; record review; environmental sweeps
Other Key Roles
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Welcome the survey team as guests in your home
Respond to what is asked – but no more than that
Be confident & professional
Don’t argue – even if you don’t agree!
Avoid defensiveness – just share what you know
Only provide factual, truthful information
Smile!!!
Survey Etiquette for Everyone
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How will we know that the survey team is here? www.jointcommission.org checked daily
between 6:45 – 7:30 a.m. Security on alert – arrange parking & greet Operator notified
Code TJC Initial alert throughout organization “Hospital XYZ Welcomes the Joint
Commission Survey Team”
It’s 7:45 a.m. and They are Here!!!
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Calling Tree initiated by Operator (with support as needed) Survey Coordinator Organization Executives Standards Experts (incl. Escorts, Blitz
Leaders, Runners) Directors
Unit/Department call lists activated (develop & assign responsibility)
Calling in the Team
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Surveyor Headquarters & Staff Command Center Activated Surveyor Room
Coffee & Orientation Packets Provided Required Documentation
Staff Command Center Surveyor Escorts & Runners – Report for
Assignments & Resources
Activating the Plan
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Calling tree notification implemented
Email notification sent
Seek Survey 911 support from Courtemanche & Associates (arrange before survey!)
Prepare staff headquarters with phones, laptops, etc. Room staffed throughout the survey (days) to
give staff the support they need and respond to all surveyor requests
Command Center Established
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Coordination of Survey Activities: Creating & Distributing Agenda
What day, what site? Sessions (all pre-prepared & practiced)
Orientation to the Organization Competence Assessment Medical Staff Credentialing/Privileging Environment of Care/LSC Medication Management Tracer Infection Control Tracer Data System Tracer Leadership
Command Center Activity
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Management must set the tone for the survey experience Staff need to see our confidence & positivity
Conduct unit/department rounds using Checklist Immediately remove all clutter Pull out Job Action Sheets and assign
responsibilities
Notify all staff & physicians
CHEERLEAD!!!!
Organizational Response
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Staff Headquarters See Key Contact Numbers All information should go through Command
Center Questions Concerns (and Uh-Ohs) Requests
Daily End-of-Day Briefings Email Updates
TIP: The goal is to mitigate survey findings and demonstrate the excellent care provided every day
Manage the Survey Process
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Immediately review survey report
Identify opportunities for Clarification
Work with Leadership to share survey results with organization
Celebrate ! ! Regardless of outcome Convey your thanks and confidence Set the stage for needed change
Manage Post – Survey Response
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The stakes are immeasurable
TJC/CMS/DOH provide the rules based on well-established criteria
Validation of performance
Successful organizations commit to imbedding those standards into the processes required to care for those in our trust
Survey = Opportunity to Demonstrate High quality, Safe Patient Care
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When the survey team arrives, When the survey team arrives, all we should worry about is all we should worry about is putting on the coffee & putting on the coffee & straightening the magazines!!!straightening the magazines!!!
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Courtemanche & Associates extends special thanks to
Saint Clare’s Health System, Denville, New Jersey
for Sharing the Concept for TJC Basic
Training and Mobilization Plan
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[email protected](704) 573-4535