Abstract

Presented at the 2024 Parkview Nursing Research Symposium.

Background: Department rounds and leadership virtual meetings were being used to prep for an anticipated Joint Commission Re-accreditation survey. Preparation did not provide a robust frontline multifaceted approach for both non-clinical and clinical co-workers which posed communication and preparedness gaps. Purpose: To develop a multifaceted approach in coworker preparation for an upcoming Joint Commission Onsite Survey by increasing staff awareness, knowledge, and understanding of the survey process. Ultimately striving for decreased survey anxiety and citations received. Methods: Preparation was developed and implemented from a multifaceted approach to include both non-clinical and clinical teams and an array of healthcare team members. Modalities included frequent consistent weekly rounds, in the moment education with utilization of closed loop communication, table top exercises by practicing the application to scenarios of information taught, development of quality, safety, infection prevention and risk (QSIR) champions on clinical and non-clinical teams in key regulatory requirements, clinical department meetings with interactive discussion, manager focused in-person meetings with virtual option, executive leadership in-person meetings with virtual option, and provider interactive education in person and via newsletter format. Key Results: Implementing a multifaceted, interactive, trust building approach provided a strong foundation for the clinical and non-clinical healthcare employees to be confident, prepared, proactive, and focus on prevention of gaps prior to the Joint Commission survey. Feedback received via Microsoft Forms survey from nursing leadership after survey recap. The Joint Commission survey citations for the hospital location received 18 total citations, 5 of which were clinically focused. This was less than the prior survey results that had a total of 20 citations, 8 of those being conditional level and 9 of those pertaining to direct clinical care. Positive verbal feedback received from surveyors, frontline staff, and leadership regarding staff knowledge, culture, and collaboration. Conclusion: Being inclusive of all disciplines from clinical to non-clinical and pairing with a level setting in a mutual respectful end user friendly manner positively impacted the number, type and severity of citations received at the designated hospital. Additionally, focusing on closed loop communication and the interpretation of standards, and using tabletop exercises helped provide in the moment education to help connect how to meet the intent of Joint Commission standards

Document Type

Meeting Abstract

Publication Date

11-2024

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