Joint Commission Survey Preparation Case Study
THE CASE: Sullivan County Community Hospital, Sullivan, IN
The Challenges
Sullivan County had been Joint Commission-certified since the 1960s. CNO Michelle Sly-Smith thought her team was in compliance…but were the patient safety measures she’d put in place sufficient? How should she begin to prepare her staff? She called on QHR to test her team’s readiness and find areas for improvement:
- Documentation in human resource files was incomplete
- Staff was not consistently taking a time out and marking sites before invasive procedures in all the units
- Team management processes were lacking
- Nutritional and functional screenings weren’t timely
- Clinical alarms had not been inventoried or categorized
- There was no policy for read-backs on critical lab results
- Directors and staff were unable to explain key procedures
Q Solutions
Observing clinical operations, reviewing charts, conducting interviews and performing a mock survey, QHR quickly identified these and other critical flaws, and developed plans to address them.
“QHR found many small issues… and a few big ones that could have caused serious citations,” Smith remembers. “We didn’t know, for example, until QHR told us, that some contract employees lacked proper licensures or competencies; we had to fix our HR processes.”
The mock survey identified that though many appropriate processes were in place, the team did not understand them well enough to explain their purpose. “It was vital that QHR identified where the gaps in knowledge were,” Smith comments. “Because between the time we started preparing and the
time the survey occurred, the Joint Commission completely revised its method. They no longer wanted to talk to directors… but to staff.”
Having started a year early, she had time to correct deficiencies and educate staff, using QHR’s recommendations.
“QHR had helped us prepare for Joint Commission surveys twice before… so we knew the value,” says Smith. “QHR’s team trains with the Joint Commission, and participates in actual surveys. So we know we’re getting accurate information.”
Networking with her peers at other QHR facilities, she also benefited from their experience. “We’re never finished. It takes due diligence at all times, because the expectations are always changing. But we’re very pleased; it was a tremendous survey.”
The Outcome
- When Joint Commission arrived early with little notice, Sullivan County was ready; it passed, with very few requirements for improvement
- The staff is not only better at explaining compliance and safety measures, it is more consistent in delivering them
"QHR's clinical team is sharp... and a pleasure to work with. They helped us find our strengths and weaknesses, and focus our efforts. The survey happened early, but our staff was well prepared."
