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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.




Joint Commission releases more FAQs

The Joint Commission has released another set of FAQs, this time addressing some emergency management, environment of care, and Universal Protocol concerns. Though you can see the full list of FAQs by clicking here, I’m going to highlight the FAQs for the Universal Protocol, as it has been a major trouble spot for hospitals and is a topic we’ve talked about in other AHAP Blog posts.

  • Bilateral procedures: The Joint Commission has addressed the issue of performing site marking for a bilateral procedure by saying it’s not required, but it is recommended. The intent of the Universal Protocol has been to specifically note the correct side of the patient for those surgeries requiring laterality, but this new FAQ was released in acknowledgement that it is possible to perform the wrong bilateral procedure.
  • Documenting the timeout: The Joint Commission has addressed the outcry it received from the field about how onerous a requirement it was to require each element of the timeout be documented individually. This FAQ specifies that it is acceptable to create a check box or brief note that documents that all parts of the timeout were completed. This simple documentation must be in the same part of a patient’s record for each patient, and the components of the full time out have to be listed elsewhere (like in a policy or procedure), but one check box will comply with the Universal Protocol.

Has your facility struggled with the 2009 Universal Protocol? Do these recent FAQs clear up any issues you may have been having with documentation?