RSSAll Entries in the "Annual Conference" Category

Contest entry: Tracer process

Another contest entry! This one comes from Robin R. Agnew, RN, BSN, MPH, senior accreditation analyst of St. Mary’s Health System, Evansville, IN. Robin writes:

To streamline the tracer process we developed a three page Core Tracer format that includes as medical record review section, a staff interview section and a brief dpt. observation section. Areas include TJC/CMS/State/NPSG as well as Magnet areas vs. having multiple tracers. The last three pages include small dpt. sections which have area specific staff interview questions pertinent for that specialty area (eg. ER, Surgery).

Tracer teams consist of a Clinical Manager or Director and a Team Partner. We find it more efficient to schedule all areas to be traced vs. have one tracer trace multiple areas. Our inpatient areas are traced twice in 6 months and ambulatory areas once in 6 months. We send reminders to each team one week prior to their scheduled time.

They review findings with the Director/Manager and send completed Tracer form to Accreditation. We post the schedule and the Quality Tracer form With answers on the Intranet so all staff knows when their area is to be traced and what will be addressed.

We plan to regularly seek feedback re. how improve process (questionnaire to Tracer teams) and input data so that reports can be run to track areas out of compliance, need follow-up, revision to tool, etc. and will review these at a monthly regulatory oversight committee.

Contest entry: Infection control staff education

Our second entry of the week comes from Megan Rose, who writes:

We improved staff education for infection control by making it fun! During International Infection Prevention Week our department hosted a POP (Protect our Patients) educational campaign. We made rounds throughout the hospital and distributed crossword puzzles and quizzes to all staff. Those that were able to complete them and turn them in received a tootsie pop.

All completed quizzes/puzzles were submitted into a drawing at the end of the week for great prizes like free meals, gift certificates for manicures/pedicures, the movie theater and more. New badge holders were distributed that said “wash your hands” and static stickers were made with the same handwashing logo and placed in the patient rooms. On the final day of the POP campaign, we had a popcorn and movie day.

We played a variety of infection control and patient safety videos throughout the day and served fresh popped popcorn. The final drawing was held at the end of the day and all were truly excited. We had great participation from all and got the message across. Thank you for the opportunity to share our story!

Contest entry: Monkey business

Our first entry of the week comes from Amy Mehlhaff, medical staff coordinator with Sheridan Memorial Hospital, Sheridan, WY. Amy writes:

In preparation for the Joint Commission Survey our Joint Commission Task Force, comprised of leaders from each of the Standard Departments, write up 10 questions they feel Joint Commission surveyors will focus on when they arrive on-site. These questions range from the NPSGs, specific standards, hand-off communication processes, etc. that all staff should be prepared for. These 10 questions are then given to our QS/MSS Administrative Assistant to type up with multiple choice answers (not that surveyors will give us that opportunity) and use to prepare an online survey through an easy, cheap, and professional tool –

Each survey is then distributed to the appropriate staff via mass email and the responses are tracked so we can assess areas that need further education. We love it so much that we now have made surveys for clinical staff, non-clinical staff, and our physicians! I encourage other facilities to utilize this tool -not promising you’ll eliminate all the other “monkey” business that goes on in the office, but at least we’ll be prepared for TJC.

This week’s winner!

I’m happy to announce that the winner of this week’s free AHAP Registration drawing is:

Janelle Holth of Altru Health System in Grand Forks, ND! Congratulations, Janelle, on winning this week’s drawing. As for all our other contestants–we’ll continue our weekly random drawings for anyone who submits a tip or tool for the blog up until Friday, April 24th!

Just a reminder…

We’ll draw a name for tomorrow’s winner of a free AHAP registration at noon. (As long as your entry is received before noon, it’s eligible for this week’s drawing, even if it’s not immediately posted.) We’ll continue to draw new winners every Friday until April 24th.

On a related note–let your friends and colleagues in the Medical Staff and Credentialing office know that the Credentialing Resource Center Symposium is holding a similar contest over on their blog right now for their annual convention (coincidentally happening the same time as the AHAP Conference). If you know anyone who was considering attending, you might want to send them to this link:

Contest entry: Oxygen tank storage

Another entry into the contest! This tip, dealing with oxygen tank storage, comes from Mary Williams, RN, Joint Commission/regulatory coordinator with Peninsula Regional Medical Center,Salisbury, MD. She writes:

Last year we switched to a “grab and go” system for oxygen tanks. The convenience has been a boost for staff but because the tanks are very mobile they began to collect in areas that had frequent transport. Unsecured oxygen tanks became a frequent finding on mock tracers and safety rounds. Because the tanks seem to multiply like rabbits, our transport group developed a schedule to collect extra tanks and return them to storage. On these “rabbit runs” they gather unsecured and empty tanks and refill storage racks. We have been able to reduce the total number of tanks in the facility and reduced the number of unsecured tanks on the floors.

Contest entry: Tracer teams

Janelle Holth of Altru Health Systems has sent in the latest contest entry, a sample document on tracer teams. She writes:

We have trained 14 teams to do tracers throughout our main facility (hospital, rehab hospital, clinics and other outpatient settings). At least once a year we have an educational session for tracer teams to provide helpful hints on the methodology for tracers. We have designed unit tracers and a NPSG tracer.

Every 3-6 months tracer teams are reassigned so that members learn from each other, the teams trace different departments and they conduct a unit specific tracer including a patient experience or a NPSG (National Patient Safety Goal) tracer.

The data from the tracer is reported to the unit manager orally and then a report is completed that is forwarded to managers for all departments that had findings within the patient tracer and to our regulatory compliance coordinator. This would include the Chief Nurse Executive and Chief Medical Executive.

We are in the process of putting all the data on a spreadsheet for review by administrative directors, executive leadership and our Joint Commission Steering Committee.

This spreadsheet is designed to allow departments to assist each other with helpful hints to gain compliance and assist with holding departments accountable for continuous compliance.

I am attaching a sample of the tracer schedule.


Contest entry: Daily goal setting worksheet

Next up we have an entry from Sandra J. Anaya, RN, with Tri-City Regional Medical Center. Sandra has sent in a daily goal setting work sheet (which we’ve posted below). Sandra writes:

We are a small facility trying to keep staff involved with JC preparedness, safety awareness, and providing continuous care. The attached tool is used for many purposes: determining a nurses knowledge of the patient, identifying any learning needs for a specific nurse or unit, keeping nurses involved with case management and discharge planning. The nurse is asked to present a “picture” of the patient by answering key questions much like a JC Surveyor would do. Other interdisciplinary team members participate. QM monitoring is included for labeling tubings, assessment of pain, etc.

The cumulative results are used as part of the PI program and reporting process as well as the competency program. Staff development is provided based on the needs identified. It takes no more than 15-20 minutes per nurse and nurses are randomly chosen each time rounds are made, which is 2-3 times per week per shift. Nursing Supervisors are responsible for conducting the rounds.

It has worked out well, particularly for new nurses who need guidance and direction. More importantly, nurses learn that their knowledge of patients is valuable to other departments and disciplines in coordinating care. It is an opportunity to update the plan of care and can serve as a team conference. We can review the chart for other things as well–signing of verbal orders, reporting of laboratory results to MDs, etc.


Contest entry: Mock codes

We  have several new entries today. The latest comes from Carolyn Weil, consultant, quality and clinical safety/risk management and regulatory compliance with St. John River District Hospital, East China, MI. She writes:

We’ve had great success with improving staff competence by conducting monthly mock codes. We are a 68-bed hospital, so resources are limited. The Nursing Educator indiscreetly places a mannequin with an attached cardiac simulator in an empty patient bed, radiology table, or any place a code situation could occur. We lure an associate into the room and present the patient’s clinical scenario. The associate initiates a “Code Blue” through an over-head page, just like the real thing. Associates assigned to the “code team” for the shift, Cardio-Pulmonary, Medical Staff, ACLS Nursing Anesthesia, and Laboratory all respond. The code progresses as the “patient’s” condition changes, as realistically as possible.

We measure the success of the mock code using 13 pre-determined criteria, such as 1 min or less from call to CPR, room set up with ambu and suction, is a lead running the code, etc. When we started doing mock codes our compliance to the 13 indicators was 45%; today our compliance is 92%. In the beginning, the associates were apprehensive and reluctant to participate. Today the associates are confident and eager to show off their skills.

Contest entry: Privacy week

Here’s our latest entry–a very timely one from Michael Neiman, senior director at Thomas Jefferson University Hospitals in Philadephia, PA. Michael writes:

Utilize Privacy week (April 12 – 18) to educate staff on requirements and standards related to privacy/confidentiality the week. Your compliance staff can assist in the preparation and educational activities so you can spread the work around.

Watch the yearly calendar for other “weeks” throughout the year to have other departments get the communications out to staff for accreditation.