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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 4 


Susan Wisniewski
Success - A Team Effort

By Susan Wisniewski, CPHQ
Manager, Accreditation and Regulatory Compliance

The Joint Commission Survey, September 2009

A team effort from the beginning, we were all working toward the goal of successful accreditation. The team work paid off when the surveyors described our staff, physicians and services as “phenomenal” and gave us high marks for compliance.  

Where did the surveyors go and what was their focus?

Surveyors visited 37 different areas of the Hospital. They went to all of the satellite intensive care nurseries, inpatient units, ancillary departments and many clinics including those located off-site. Home care surveyors spent three days with Home Care staff reviewing records and accompanying staff on home visits. 

The surveyors focused on the environment, communication, patient safety and security, medication use and storage, infection control, confidentiality, documentation, National Patient Safety Goals and Performance Improvement. All of these topics are part of our Priority Focus Areas, or areas that we focus on daily.

What were our results?

While we were very successful in our recent survey with minimal findings, there is still room for improvement. Surveyors now cite findings based on a level of criticality – the immediacy of risk to patient safety or quality of care. There are “direct impact” and “indirect impact” findings with direct impact requirements higher on the criticality scale because they create an immediate risk. 

Each of the findings must be addressed in an Evidence of Standards Compliance Report which includes written action plans and time lines for completion. These plans address issues of documentation in the areas of patient education, risk assessments for infection control, emergency management drills and authentication of entries in the medical record.

Nursing and physician leadership have participated in the development of these plans and have designed and implemented a data collection process to demonstrate our compliance. Once submitted, these plans were approved by The Joint Commission and data is collected for four months and re-submitted. It is only after a consistent compliance rate of 90% or higher is reached that our final accreditation letter will be sent. 

How did we achieve such success? 

  • Staff, clinical and non-clinical work together
  • Staff have an interest in delivering high quality care
  • Staff focus on patient safety
  • Staff participate in patient tracers
  • Staff are loyal, dedicated and provide compassionate care
  • Strong leaders are well educated in regulatory issues as well as patient care
  • Senior leaders understand the importance of patient safety and performance improvement

The organization was recognized as having a “best practice” in the following areas:

  • Medical Staff was recognized for its outstanding physician evaluation program
  • Clinical Education was complimented on the excellent assessment and planning for orientation and continuing education for clinical staff
  • The Fall Prevention Program was commended for the development of an assessment unique to the patient population
  • Patient Safety in the Operating Room was acknowledged for its consistent use of a “time-out” process

Our staff made the difference between an excellent survey and one that was just “ok.”  When we were in the spotlight, our staff demonstrated the Hospital’s core values of excellence, integrity and collaboration. Congratulations on our success! 

In This Issue

A Decade of Difference

National Certifications

The Benefits of Certification

A Journey to National Certification

A Vision for Advanced Respiratory Therapist Credentialing

The PICU's National Certification Journey

Working for a Living

Success - A Team Effort

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