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Surprise!
Ten top tips to help you sail through the survey when the Joint Commission pays its unexpected call


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Unless you’ve been living under a rock lately, you know that The Johns Hopkins Hospital is due for a Joint Commission inspection this year and that for the first time the visit will be unannounced.

Our last survey took place in November 2004. It was a regularly scheduled, triennial event for which staff had months to prepare.

Now, unannounced inspections, which can take place anywhere from 18 to 39 months after the last survey, require staff at hospitals everywhere to be always on their toes. No more resting on one’s laurels. No more scrambling around at the last minute to pass muster.

To ease the way, a Web site has been designed to aid physicians, staff and managers. For extra advice, we consulted Susan Franklin, the hospital’s new director of regulatory affairs, for tips on how to sail through the survey with flying colors. Here’s what to know:

1. How to prepare at the last minute.

At 7 a.m. on any Monday, Tuesday or Wednesday between now and Dec. 31, surveyors will notify us on their secure extranet site of their imminent arrival. Word will go out throughout the institution, and at 8 o’clock sharp, they’ll be on our doorstep.

From 8 to 9, surveyors will meet in Billings to review all documents they requested. From 9 to 10, they’ll meet with senior administrators. We have three hours in which to prepare. It would be foolish not to make good use of them. For help, check out “Just-In-Time” on our Web site.

2. National Patient Safety Goals.

They’re 90 percent of the survey. The goals appear on the Web site, on the new laminated badge tags, and in Clip’s Tips, the spiral-bound accreditation guide booklet.

3. Universal Protocol.

Universal Protocol, sometimes called Universal Standard, includes three elements: preverification checklist, site marking and a final timeout involving the entire surgical team. The Joint Commission is quite serious, incidentally, about timeouts.

4. How to manage a fire or other emergency.

What to do in the event of a fire should be drilled into everyone. Disaster planning will be a focus. Staff should be able to articulate an evacuation plan and say what their role would be in, say, a code yellow.

5. How your area improved patient safety.

Surveyors are tired of organizations collecting data but not using it to make improvements. Staff should be able to talk about actual improvements like what’s been done to prevent patient falls. These should be shared by managers regularly with everyone.

6. Principles of infection control.

Clean your hands! Clean your hands! Clean your hands!

7. Details of your professional training.

How were you trained in infection control, fire safety, emergency management and other core competencies? Be able to describe your orientation to the hospital and your job and outline your credentialing and ongoing education.

8. Principles of effective communication.

What steps have been taken to improve communication from site to site, provider to provider, unit to unit? Communication during hand-offs is most important.

9. How your area protects patient privacy.

Open computer screens, charts laying out, patients’ full names openly displayed on nursing units—such indiscretions compromise patient privacy.

10. The rights of patients—and the public.

A big focus is on giving patients and the public the ability to report safety and quality concerns. Surveyors will look to see if we have provided instructions and encouragement to patients and the public to report concerns to the Joint Commission if the hospital is unable to resolve them.

—Anne Bennett Swingle

 

 

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