setting the stage for a successful survey. tjc extranet is checked daily key staff have job action...

Setting the Stage for a Successful Survey

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


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


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


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


Leadership Team Drivers

Management Coaches

Staff Star players

Survey Support

Surveyor Escorts Guides

Scribes Documenters

Runners Assistants Messengers

Blitz Leaders Staff support


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?


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?


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?


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?


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?


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?


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?


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?


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


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!


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


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!


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


Participate in survey process

Oversee “job action” responsibilities

Exude positivity & confidence

Provide support, encouragement & praise to staff

Management – Go Coach!


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


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


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


It’s Survey DayIt’s Survey Day


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!!!


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


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


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


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


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


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


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


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


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!!!


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


[email protected](704) 573-4535