Readiness strategy leads to successful Joint Commission survey
Recently, 11 surveyors spread out across Cincinnati Children’s for our triennial Joint Commission survey of the Hospital, Behavioral Health and Home Care programs. Although we’ve been through this countless times before, it was obvious from the first day that something was different.
There were smiles. Employees spoke with excitement and confidence about their work. As one surveyor noted, “Your staff didn’t act like they had been coached on what to say. They stepped up and spoke from the heart about why they loved their job and their role in serving patients and families. And most impressively, their competence and skills were second nature.”
So what changed?
Our new approach to accreditation surveys began 3+ years ago when Accreditation Services restructured within the Anderson Center.
“Three years ago when we imagined how we might do this work, we said that surveys are an opportunity to learn,” recalled Jeff Simmons, MD, MSc, Safety Officer, in the Anderson Center, who along with Mary Sitterding, PhD, RN, vice president, Patient Services, helped lead the improvement effort. “We laughed then, but it worked!”
According to Mary Jo Goebel, MSN, RN, director of Patient Safety, Accreditation and Regulatory, every clinical area has a go-to person in Accreditation and Regulatory Affairs (ARA) whom they can partner with to meet Joint Commission and other regulatory standards. This collaboration helps the medical center maintain a constant state of readiness.
Said Cindi Bedinghaus, MSN, RN, assistant vice president, Patient Services, “Our teams were so prepared because of ARA. People knew who to reach out to when they had questions, and the ARA consultants were so responsive and willing to help. It’s a totally different dynamic. The ARA team members really get to understand the processes of the areas they’re assigned to and develop a connection with frontline staff, which is phenomenal.”
That level of preparedness resulted in no findings regarding ligatures (restraints), high-level disinfection and infection control—all high-risk areas that have been a priority focus this past year.
Additionally, some areas that have had concerns during previous surveys had stellar results (e.g., Dialysis, Dental and the Hospice bereavement program).
Several programs were surveyed for the first time—Fetal Care, the food pantry in the Pediatric Primary Care Center and the TIP preschool—and they received exceptional recognition.
Overall, the surveyors were impressed with our focus on safety, as demonstrated by our “flawless” performance of time-outs, infection control measures and use of personal protective equipment.
A team effort
Following the survey closing session on Friday afternoon, senior leaders expressed their appreciation for all employees, including the ARA team, for their outstanding representation of Cincinnati Children’s.
Said Steve Davis, MD, Chief Operating Officer, “WOW, WOW and more wow! This is, I think, my 20th survey in one form or another, and it’s absolutely the best I’ve ever been a part of. The surveyors were so complimentary and, at times, amazed at what they saw. This doesn’t happen without a fanatical dedication to being the best we can be. It is an honor to work with all of you and your teams.”
Michael Fisher, president and CEO, agreed, saying, “This has been one of the best weeks in my 10 years here, seeing what all 16,000 of you are doing and how the new strategy is coming together. Many department and division leaders are relatively new to their role, but it’s clear we’ve taken it up a notch, if not more. I couldn’t be prouder of our entire team and especially their dedication to doing our very best for every patient and family we’re privileged to serve.”
