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Contest entry: NPSGs

Our second entry of the day comes from Sue Courtney RN, BSN, director of quality services with Memorial Health Center in Medford, WI. Sue writes:

At our facility, we’ve photographed staff to use for somewhat humorous safety posters focusing on the NPSG’s. The favorite so far is the one encouraging two patient identifiers with a picture of one of our nurses saying she’s here to check fetal heart tones while one of our EMT men is in the bed.

We’ve also videotaped a “falls” room that has various “no ,no’s” throughout the room and staff identifies what items may put a patient at risk for falls and completes a list for educational credit. By videotaping, we are able to use the material throughout the year.


Contest entry: Organization-wide communication

Our latest entry comes from Jean Knutson, MS, RN-BC, accreditation manager at Avera McKennan. Jean writes:

My tip is really for large organizations…..it is so hard to reach the masses. We have an organization-wide daily line up communication message that all employees attend in person in their own unit/department every day. It is a great communication tool for all! I have added a Joint Commission Tip of the Day to this organization-wide message. It has generated much interest and I get lots of questions around the tips!


This week’s winner is…

This week’s winner of a free registration to the 2009 AHAP Conference is: Kathy Johnson, director of quality management and survey coordinator for St. Luke’s Hospital in Duluth, MN!

Kathy submitted a sample survey action plan to the contest.

Congratulations, Kathy! If you haven’t sent in your entry yet, there’s still plenty of time-the next drawing will take place a week from today, April 3rd. We’ll be drawing a winner every Friday until April 24.


Last post before this week’s drawing…

The following contest entry arrived just moments before our noon deadline–another great tip, this time fromNancy A. Cuccaro, administrative director, QM, with Huntington Hospital. Nancy writes:

Making the first 30 minutes go smoothly sets the tone for the rest of the survey. Anxiety can be high, and it’s easy for people to forget “What To Do….” Key departments [Security, Front Desk, Dietary, Housekeeping, Information Services, Switchboard, and my own office – QM] were each given one-page guides for what to do, what to say, what number to call. Months before the anticipated survey timeframe, and again as the probable date came closer, we practiced the plans. Doing so one-on-one assured me of two things: first, that they knew about the plan and where to find it; second, that they were comfortable it was logical and workable. When the day came and I saw the saw notice posted [at 7:12 a.m.] my anxiety level was reduced because I didn’t have to think about what to do next….my plan and my phone call tree were already in place. The people I called were more relaxed for the same reason. By the time the surveyors arrived almost everything needed for the opening session was already in place, in a vacated conference room, with a coffee and breakfast set-up. This continued throughout the survey, as everyone slated to participate in the Systems Tracers, Credentialing and Leadership sessions, etc., already knew when and where they’d be needed, and all we had to do was to let them know the survey had started.

One additional comment: If you can arrange it, have a member of the voluntary medical staff participate in as many of the tracer visits as they can. Two of our MDs cleared their schedules – the surveyors were very impressed and the physician input was invaluable.



Contest entry: Right soap, right settings

The contest continues with the latest tip fromJane O’Glasser BSN, RN, infection control coordinator with the Multnomah County Health Department in Portland, OR. She writes:

Our county health department has over 20 clinical settings that are serviced by a minority janitorial service. As we switched to antimicrobial soap in our clinics, the concern as to how our janitors would be able to distinguish the right soap for the right settings was raised. I searched the literature, talked with other ICPs, consulted with our QA officer, and facilities staff.

We decided to put automatic soap dispensers into our clinical areas and manual dispensers in non clinical areas. The replacement soaps fit only into the dispenser it is meant to have. In addition, the dispenser is labeled “Antimicrobial” on an orange label, which matches the orange writing on the soap replacement label. Conversely our green soap for non clinical areas has a green label with information about the product on the outside and the replacement soap’s labeling is in green lettering.

We’ll be drawing a winner from all contestants at 12 pm EST today. But remember, if you haven’t submitted a tip to be entered into the drawing yet, there are still more opportinities to win–we’ll be drawing a winner every Friday until April 24!

Contest entry: Hand hygiene

Another tip, another entry for free registration at this year’s 2009 AHAP Conference! The latest comes from Mary Lou Love, MSN, RN, infection control practitioner out of Edinburg, TX. She writes:

To enhance hand hygiene we had one of our leaders submit his picture and placed his picture on the screensaver along with our message on hand hygiene so that his peers and all of our healthcare providers would see that we all want to make a difference. He said we all need to jump in and help where ever we can.

Contest entry: Unannounced survey plan

Today’s first entry into our contest comes fromJanelle Holth, RN, BSN, regulatory compliance coordinator at Altru Health System. She sent in the attached survey preparation switchboard, with the following description:

We had our first unannounced survey in October 2008. Our “Unannounced Survey Plan” assisted our entire organization to be well prepared to welcome the survey team to our facilities. I worked with a committee consisting of 8 employees (Executive leadership, managers, coordinators) from various areas in our health system. As this committee gathered information, we would meet every two weeks to design and update the Unannounced Survey Plan. Once the plan was finalized, education about the plan was brought to all levels of leadership. We subsequently scheduled two mock surveys (about 6-8 months apart) allowing us to test our plan and make necessary changes. The goal of utilizing this plan was to assure good communication to our survey team and the employees of our health system. We believe that organization and communication are key to setting the tone of the survey from the moment the surveyors enter our front lobby. Detail was added to the survey plan so that all staff involved were well aware of their duties.

We functioned with a “command center” all week. The command center was equipped with computers, a printer and staffed by a minimum of 3 employees. Information flowed in and out of our command center allowing us to bring surveyors and escorts policies, guidelines and documents timely if requested. The command center managed the day to day operations, scheduling for special sessions and directed communications to appropriate staff. Executive leadership contacted this center for updates on the progress of the survey.

Staff were available and involved with tracer activities and special sessions. The survey team observed the “culture of safety” set forth by our leadership team and commended our staff for their compassionate patient care.

The survey team thanked us for being prepared, organized and responsive to their requests during the exit briefing. I believe the detailed design of our unannounced survey plan assisted employees to be involved and ready for a survey. The command center was a vital component for day to day operations throughout the survey process.

The switchboard can be downloaded here:

unannounced-survey-jc-switchboard

Thanks for a great entry, Janelle!


Screen savers as education tools

Another entry to the contest! This comes fromMichael Neiman, MHA, CPHQ, senior director of accreditation/regulatory affairs at Thomas Jefferson University Hospitals in Phiadelphia, PA. His tip:

We utilize our screen savers to communicate reminder information to staff as part of continuous survey readiness. Information includes National Patient Safety Goals, Performance Improvement, Infection Control, Environment of Care, Medical Record Documentation, and Patient Satisfaction results. This serves as constant reminders and has been extremely effective with communication. We keep them current and change them every few weeks.


Next up: National Patient Safety Goals

the entries for our AHAP Conference registration giveaway keep coming in. Here’s another tip, fromCarla Brown, RN, patient safety officer and clinical leader for the emergency department at Forest Park Hospital. Her story:

Our hospital held an event to review National Patient Safety Goals, accreditation requirements, and other mandatory subjects. It was required of all employees, clinical and non-clinical. Employees were scheduled to attend at specific times.

To make it fun and memorable for everyone, we created a nautical theme. Titled “Cruise to Excellence,” we had numerous “ports of call” which focused on various educational topics. Team members depicted the “crew” from Gilligan’s Island, and.it actually was a “3 hour cruise.” We randomly assigned teams, who competed against each other to win prizes (such as lunch at the Forest Park Boathouse with our CEO). We even had a grand prize of an actual cruise! We spoke “pirate,” we sang karaoke at “Forest Park Idol”, and we sent shipmates to the “Poop Deck” if they didn’t cooperate. It was great fun, employees bonded with each other, everyone’s morale was boosted, and best of all….performance reviews showed marked improvements in safety and quality measures after the Cruise! We proved that everyone (from dietary aide to security officer to nurse, and so on) was better able to follow through with what was taught when the lessons were interactive, energetic and fun!


Contest continues with a site marking tip

Let’s start the day with yet another entry in our 2009 AHAP Conference registration giveaway. Our first tip today comes from Barbara Swisher, RN, quality coordinator of Abilene Regional Medical Center in Abilene, TX. She wrote:

This year we are very fortunate to have an active Chief of Staff. He is a general surgeon who never really understood site marking to its full intention. After some education, he was “on board” to educate the remainder of the Medical Staff. He deserves full credit for our successful program. First he wanted education in several forms: A construction sign with a flashing light used for recent renovations was placed in the Physicians’ Dining area with information on site marking and the cautions to take – laterality, level, etc. Then each physician on staff received a certified letter with a small clickie Sharpie ® with the words “Yes Marks the Site.”

A date was set where the C of S, CNO, COO, Surgical Services Director, Invasive Radiology Director, Cath Lab Director, and Quality Director met in the Day Surgery Unit (DSU) at 6 pm where they would be able to “further educate” any physician with questions or opposition. No patient who required site marking was allowed to leave the DSU without the LIP marking the site. The sites are now marked by the Surgeon in the DSU, occasionally with a little under-the-breath speech, with the patient actively involved and the DSU staff documenting on the Universal Protocol form.

More tips yet to come today–keep those entries coming!