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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.

Joint Commission revises… revised standards

The Joint Commission has, after discussion with CMS, reduced the number of changes from its January 5, 2009 announced standards revisions. According to the official announcement, the changes followed discussion with CMS (and Joint Commission’s deeming authority application) during which it was determined that a number of the requirements were already covered under existing standards or otherwise in the Joint Commission survey process.

The Joint Commission has published the changes here. A crosswalk of the March and January standards revisions is available here.

Stay tuned for further analysis…

Positive Deviance proven to lower MRSA rates

The Robert Wood Johnson Foundation and Plexus Institute today announced the results of a Positive Deviance program, trialed to see the effects it had on MRSA rates. The story caught my eye because I’ve written a couple of stories about Positive Deviance for Briefings on Patient Safety in 2007 and 2008, and the idea always struck me as something so simple, yet so empowering. Positive Deviance solicits ideas for solving a problem from those who deal with that problem often and may think of a solution that might be considered “out of the norm,” but one that works. It’s an approach that attempts to gather behavioral change from those frontline workers who solve problems with the same resources as their peers.

Using Positive Deviance to lower MRSA rates has succeeded, as it was announced at the annual scientific meeting of the Society for Healthcare Epidemiology of America this past weekend. The study began in 2006 and introduced the idea of Positive Deviance into three hospitals from different parts of the country. Each hospital was to use Positive Deviance to help carry out the following three actions:

  • screening all patients admitted to a pilot unit for MRSA
  • isolating all patients who tested positive
  • rigorously adhering to hand hygiene and contact precautions

A team from the Centers for Disease Control and Prevention analyzed the data from these facilities to show a reduction in MRSA rates between 26 and 62%.

This video clip from CBS News shows how one transporter helped his hospital adhere to hygiene and contact precautions (sorry about the commercial before the news).

Could this technique be something your hospital implements? Have you thought of using Positive Deviance for tackling other issues at your facility, not just MRSA?

You can find out more about Positive Deviance by visiting the Positive Deviance Initiative Web site.

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:


Thanks for a great entry, Janelle!

More continuous survey tips

Ladies and gentlemen, our fourth entry of the day in our AHAP Conference registration giveaway. Our latest comes fromCathy Rowden, accreditation director at Skaggs Regional Medical Center in Branson, MO. She writes:

Each survey we pick a theme to help promote awareness for the survey. This year’s theme is “survivor.” We kicked it off with a National Patient Safety Goal day of learning. We had stand up posters made by each national patient safety goal team to remind staff of the goal. We decorated the rooms in less than 30 minutes, had refreshments, music, video’s going on national patient safety goals that we produced. People love to see themselves and co workers on the screen, and it was a huge success. Not labor intensive. Gave away several prizes for attendees. Following that we did a power point presentation on line for those that were unable to get to the event.

Finally we followed up with an online test covering all the national patient safety goals. It was a hit, it tells us where our “trouble” spots might be, and the staff loved it.

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, 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!