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Contest entry: Continuous readiness

Our latest entry comes fromTricia Elliott, coordinator of accreditation and licensure in the quality/patient safety department at St. Alexius Medical Center in Hoffman Estates, IL. Her tip:

For our 2009 PPR, we are having small group meetings with the content experts for each chapter. During the meeting we are online with the PPR tool, and scoring the individual EPs. There is room on the PPR tool to enter additional information that is needed (or researched) to determine compliance, or an action plan is developed for a non-compliant EP. Those EPs that are not at satisfactory compliance are brought to a Task Force for further review and additional input into the action plan process to ensure the appropriate steps are taken to become compliant. Also, the Task Force pays special attention to the “challenging” standards published by The Joint Commission to ensure continuous readiness and compliance in the more challenging areas.

Contest entry: PPR tip

Another entry! This one comes from Lisa Kulp, RN, MS, CPHQ, accreditation specialist at Grant Medical Center.  Her tip:

When it is time to conduct the annual PPR assessment tool for Joint Commission standards, we have also added a review of the CMS Conditions of Participation standards at the same time. This will assist our facility to conduct a more thorough review of the standards that we are expected to be in compliance with at all times.

Leadership standards tip

Our latest tip/contest entry comes from Yvonne Y. Jones, RN, BSN, MHA, CPHQ, on standard LD.04.03.07:

If your organization provides an educational service in a classroom setting Monday through Friday but not on the weekends make sure that the educational content is the same for patients who require the service on weekends. The service must always be, even in the classroom setting, based on individual needs and assessment. If asked why the classroom setting… the appropriate response would be to to educate a larger number simultaneously but each lesson is tailored to individual assessments and needs. Patients receive the same content based on identified needs no matter what setting the education takes place in.

Contest entry: Continuous readiness

Because we received so many entries yesterday, we’re going to post several entries today. Our second entry comes from Courtney Staloch, director of performance improvement at Oakleaf Surgical Hospital in Eau Claire, WI. Her tip:

Two years ago, my small facility put together employee tracer teams in preparation for its upcoming JC survey. For those who volunteered, we provided classroom training, tracer tools, and a feedback loop for findings to reach the “traced” areas and the leadership team. The expectation was that there would be 1 tracer per week (revolving teams), each team would do “Just In Time” training with staff during the tracer (in response to observed compliance issues), and summarize their findings for the coordinator.

Each team started with a lead “surveyor” (someone with knowledge of JC standards & previous survey experience) as well as 2 trainees. We were surprised to find the trainees quickly became adept enough to trace on their own! It was a great way to engage staff in the process and relay knowledge. So good in fact, that we continued the tracer teams after we passed our survey with flying colors.

Keep those entries coming! We’ll draw this week’s winner for a free registration to the AHAP Conference in May on Friday.

AHAP Conference giveaway entry: Survey action plan

Our contest continues! We’ll be posting several entries today since we had a bunch of folks jump in the ring yesterday to submit tips for the contest. Our first entrant is Kathy Johnson, director of quality management and survey coordinator for St. Luke’s Hospital in Duluth, MN. She’s sent in a sample Joint Commission Survey plan. Kathy had this to say:

It was helpful in making sure key tasks were quickly accomplished on the opening and subsequent days of our first unannounced survey. I hope others find it useful.


AHAP Conference giveaway: Today’s entry

Our latest entry in the 2009 AHAP Conference free registration givewaway comes from Tricia Elliott, coordinator of accreditation and licensure in the Quality/Patient Safety Department at St. Alexius Medical Center. She shares this anecdote:

When we had to implement our Universal Protocol form to the units (for bedside procedures), we wanted to effectively communicate to all staff members. A PowerPoint presentation was developed that was communicated to staff via our HealthStream online education tool. To encourage people to complete the HealthStream, we sent information out to the nursing leadership to use in their staff huddles, unit meetings and department meetings. We also followed up with email reminders. By using all the communication tools available, we are able to get the word out to staff on following Universal Protocol. 

More entries are on the way. We’ll be drawing our next winner this coming Friday. Questions? Email me at

This week’s winner!

We have our first winner in our weekly drawing for free AHAP 2009 registration:

Sharon Brauer of Alexian Brothers Medical Center!

Congratulations, Sharon. Thanks to everyone who participated this week–and remember, we’ll continue drawing a winner every Friday until April 24th from all entrants into the contest, so stay tuned to the blog for future winners.

Keep those tips, tools, and stories coming. I’ll continue to post all entries to the blog as they arrive. Congratulations again, Sharon, and good luck to the rest of our entrants, as well as everyone else who would like to participate

Want to submit a tip to be entered into the drawing? Email me at

Today’s contest entry tip

Our AHAP Conference registration giveaway continues! Today’s entry comes from Sharon Mosenfelder, RNC, Trinity Clinics quality and safety manager with Trinity Medical Center. Sharon had this to say about survey preparation in a health system:

Our out patients clinics (14) are hospital affiliated and are accredited by Joint Commission. We are due for survey this year and since February 1st our focus is on staff education to achieve 100% compliance for the National Patient Safety Goals. I have been attending staff meetings at each clinic and doing power point presentations on the ABC’s of each requirement. The staff is then given a short quiz, which is then reviewed. It only involves a short period of time during the meetings and I am getting a getting a positive input from staff and they get 100% on the post tests!

Our first winner will be announced tomorrow, so there’s still time to enter this week’s drawing. We’ll be selecting a winner every Friday from now until April 24th. All you need to do to enter is send in a tip, anecdote, success story, best practice, tool–anything accreditation related that we can share with AHAP members here on the blog.

Question? Email me at And thanks to everyone who has participated so far!

AHAP Conference giveaway entry: critical values

Our AHAP Conference registration giveaway continues with today’s entry, from Deborah Vlahov, BS, RN, director of accreditation and patient safety at Brookhaven Memorial Hospital Medical Center in Patchogue, NY. Debbie had this to say:

Here is an audit tool we developed for measuring critical values form the lab. Also including the purple sticker we use. Hope you find it useful.

Below you’ll find attached an audit, revised report, and sample sticker used in her organization’s program. Thanks to Debbie for sending in the latest entry. And remember, there’s still plenty of time to enter–click here for a complete description of the contest.




Contest Entry: Continuous readiness

Let’s start off the week with our second entry into our free registration to the 2009 AHAP Conference in May. Rules and details can be found in this post. Today’s entry comes from Ronda Reimer, special projects and Joint Commission coordinator with Pella Regional Health Center. She wrote about a recent campaign to improve continuous readiness:

Two years ago upon initiating a continuous readiness campaign I struggled with how to reach the staff and impact their understanding of the regulatory issue that impacted patient safety within the areas of practice.

In the old days we held Joint Commission day “learning fairs” where it was mandatory for all clinical staff to attend. The feed back received from these fairs indicated staff did not want to come in on their day off to attend mandatory inservices.

After much thought, I decided to launch a virtual readiness campaign. The fun part was developing a theme that would be fun and interesting! This was sort of a gamble also however we did not feel we had a lot to lose. The virtual continuous readiness campaign consisted of brief power points posted for staff to access during their shift when it would not detract from patient care.

By accessing the power points they learned about the NPSGs and other regulatory information and mixed in the presentation were virtual quizzes. At the end of each power point the staff member who completed could follow the instructions to print of a certificate of completion and were asked to copy and forward it to the education department.

The education liaison entered participation in to an excel spread sheet and the spread sheets were managed by department managers and lack of participation was reflected in the annual employee review. Participation was rewarding by quarterly drawings for small prizes.

The ultimate reward was when the surveyors showed up on our doorstep on January 13, 2009! I can not tell you how proud I was of our staff! They were so well prepared the surveyors asked me what it was we were doing in our institution to prepare our staff so well. I was so pleased! We will continue with the readiness campaign this year following the survey on a quarterly basis. After all it is “continuous readiness!”