Physicians can take some simple but important steps to help SHC show the Joint Commission the high quality of care at SHC, but they’re going to have to be “ever ready” during 2007.
For the first time at Stanford, the surveyors from the JC (formerly the Joint Commission on the Accreditation of Healthcare) will arrive unannounced and conduct a visit based on “tracer methodology,” explained Pepe Greenlee, accreditation and regulatory quality manager at SHC. She has been working with an interdisciplinary team, including physicians and key hospital executives, to make sure the institution will demonstrate accountability in the rapidly changing healthcare marketplace.
“The good news is that the standards and quality care are more synchronized than I have ever known them to be,” noted Chief of Staff Larry Shuer. “These are truly ‘real world’ preparations for quality care.”
Key personnel involved with the survey will receive a 6 a.m. text message that the team is enroute that day, Greenlee said. The rest of the hospital will be notified via email and an overhead announcement just before 8 a.m.
The “tracer methodology” is one of the innovations the JC has been using since the organization began unannounced visits of healthcare institutions in January 2006. Previously, the Joint Commission would schedule visits, permitting the hospital to orchestrate a formal presentation for the surveyors.
Greenlee describes “tracer methodology” this way:
“The Joint Commission surveyors select a patient and use that individual’s medical record as a roadmap to move through an organization to assess and evaluate the hospital’s compliance with selected standards and systems of providing care and services.”
Since physicians will only have an hour or two at most to prepare, Greenlee and the hospital team is asking physicians to “know the National Patient Safety Goals and be able to describe your role in compliance with the standards to surveyors who will likely stop and ask physicians specific questions to test their knowledge of safety policies.”
For example, physicians are expected to be able to describe:
The SHC “time-out” (Boarding Pass/Universal Protocol) procedure.
The “do not use” abbreviation list; CPOE is one way that SHC limits the abbreviations used in orders.
The medication reconciliation process and how the patient’s medication list is communicated between providers and levels of care.
The SHC Infection Control guidelines, including hand hygiene practices when working with patients.
Caregivers should also be familiar with the quality improvement activities for their service. For example, peer review, M&M (mortality and morbidity) conferences, and case conferences are several examples of performance improvement activities. Also physicians should be able to explain that they report adverse events in the patient safety net (PSN) system.
“Be familiar with the core measures that apply to your area - acute myocardial infarction (AMI); community acquired pneumonia (CAP), heart failure; surgical care infection prevention (SCIP),” Greenlee explained.
And during the survey, “physicians may be asked to participate in the interdisciplinary team interview if the tracer team is visiting your unit or department. Answer survey questions to the best of your ability. If you are not sure of the answer, be ready to state where you would go to find out the information,” said Greenlee.
The longest hospitals can qualify for a survey is three years.
The team visiting will likely include at least four JC and one or two Institute of Medical Quality (IMQ) surveyors. A California Department of Health Services (DHS) surveyor may also be on the team, Greenlee said.
“Put simply, it’s important to meet or exceed Joint Commission standards,” said Shuer. “Results are posted on the web for the public to view, and we want to assure prospective patients that SHC meets high performance standards. It should be encouraging for all of us that the preparations that we and an interdisciplinary team have been making are genuinely ‘reality based’, intended to contribute to raising the level of patient care,” the chief of staff concluded.
For the first time at Stanford, the surveyors from the JC (formerly the Joint Commission on the Accreditation of Healthcare) will arrive unannounced and conduct a visit based on “tracer methodology,” explained Pepe Greenlee, accreditation and regulatory quality manager at SHC. She has been working with an interdisciplinary team, including physicians and key hospital executives, to make sure the institution will demonstrate accountability in the rapidly changing healthcare marketplace.
“The good news is that the standards and quality care are more synchronized than I have ever known them to be,” noted Chief of Staff Larry Shuer. “These are truly ‘real world’ preparations for quality care.”
Key personnel involved with the survey will receive a 6 a.m. text message that the team is enroute that day, Greenlee said. The rest of the hospital will be notified via email and an overhead announcement just before 8 a.m.
The “tracer methodology” is one of the innovations the JC has been using since the organization began unannounced visits of healthcare institutions in January 2006. Previously, the Joint Commission would schedule visits, permitting the hospital to orchestrate a formal presentation for the surveyors.
Greenlee describes “tracer methodology” this way:
“The Joint Commission surveyors select a patient and use that individual’s medical record as a roadmap to move through an organization to assess and evaluate the hospital’s compliance with selected standards and systems of providing care and services.”
Since physicians will only have an hour or two at most to prepare, Greenlee and the hospital team is asking physicians to “know the National Patient Safety Goals and be able to describe your role in compliance with the standards to surveyors who will likely stop and ask physicians specific questions to test their knowledge of safety policies.”
For example, physicians are expected to be able to describe:
The SHC “time-out” (Boarding Pass/Universal Protocol) procedure. The “do not use” abbreviation list; CPOE is one way that SHC limits the abbreviations used in orders. The medication reconciliation process and how the patient’s medication list is communicated between providers and levels of care. The SHC Infection Control guidelines, including hand hygiene practices when working with patients.Caregivers should also be familiar with the quality improvement activities for their service. For example, peer review, M&M (mortality and morbidity) conferences, and case conferences are several examples of performance improvement activities. Also physicians should be able to explain that they report adverse events in the patient safety net (PSN) system.
“Be familiar with the core measures that apply to your area - acute myocardial infarction (AMI); community acquired pneumonia (CAP), heart failure; surgical care infection prevention (SCIP),” Greenlee explained.
And during the survey, “physicians may be asked to participate in the interdisciplinary team interview if the tracer team is visiting your unit or department. Answer survey questions to the best of your ability. If you are not sure of the answer, be ready to state where you would go to find out the information,” said Greenlee.
The longest hospitals can qualify for a survey is three years.
The team visiting will likely include at least four JC and one or two Institute of Medical Quality (IMQ) surveyors. A California Department of Health Services (DHS) surveyor may also be on the team, Greenlee said.
“Put simply, it’s important to meet or exceed Joint Commission standards,” said Shuer. “Results are posted on the web for the public to view, and we want to assure prospective patients that SHC meets high performance standards. It should be encouraging for all of us that the preparations that we and an interdisciplinary team have been making are genuinely ‘reality based’, intended to contribute to raising the level of patient care,” the chief of staff concluded.
