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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?

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!”

Our first entry to the contest

I’d like to thank Sharon Brauer of Alexian Brothers Medical Center for being our first entry into our AHAP Conference registration giveaway. She has sent in a sample tool for improving patient identification, which I’ve attached here.

Thanks, Sharon, for kicking off the contest for us!

Click on the link below to view the sample tool:

Patient ID Tip

Win a free registration to AHAP ’09

In an effort to make this year’s AHAP Conference as accessible and fun as possible, we’ve decided to run a contest–and each week, we’ll hold a drawing for a free registration to the conference! All you have to do to enter is submit a Tip of the Day for the AHAP Blog.

The rules are simple: write up an accreditation-related tip on the topic of your choosing-a tool you’d like to share with other AHAP members, a story about a recent survey, a short post about how you’ve improved staff education on infection control or how you’re meeting a National Patient Safety Goal, for example. Simply email your tip to me at I’ll post it to the blog as each entry arrives, and you’ll be entered to win a weekly drawing for registration to the conference!

We’ll announce the winners each Friday morning. The contest will run through Friday, April 24th. Questions? Feel free to email me for details. Looking forward to hearing from you!