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Contest entry: Oxygen tank storage

Another entry into the contest! This tip, dealing with oxygen tank storage, comes from Mary Williams, RN, Joint Commission/regulatory coordinator with Peninsula Regional Medical Center,Salisbury, MD. She writes:

Last year we switched to a “grab and go” system for oxygen tanks. The convenience has been a boost for staff but because the tanks are very mobile they began to collect in areas that had frequent transport. Unsecured oxygen tanks became a frequent finding on mock tracers and safety rounds. Because the tanks seem to multiply like rabbits, our transport group developed a schedule to collect extra tanks and return them to storage. On these “rabbit runs” they gather unsecured and empty tanks and refill storage racks. We have been able to reduce the total number of tanks in the facility and reduced the number of unsecured tanks on the floors.

Contest entry: Tracer teams

Janelle Holth of Altru Health Systems has sent in the latest contest entry, a sample document on tracer teams. She writes:

We have trained 14 teams to do tracers throughout our main facility (hospital, rehab hospital, clinics and other outpatient settings). At least once a year we have an educational session for tracer teams to provide helpful hints on the methodology for tracers. We have designed unit tracers and a NPSG tracer.

Every 3-6 months tracer teams are reassigned so that members learn from each other, the teams trace different departments and they conduct a unit specific tracer including a patient experience or a NPSG (National Patient Safety Goal) tracer.

The data from the tracer is reported to the unit manager orally and then a report is completed that is forwarded to managers for all departments that had findings within the patient tracer and to our regulatory compliance coordinator. This would include the Chief Nurse Executive and Chief Medical Executive.

We are in the process of putting all the data on a spreadsheet for review by administrative directors, executive leadership and our Joint Commission Steering Committee.

This spreadsheet is designed to allow departments to assist each other with helpful hints to gain compliance and assist with holding departments accountable for continuous compliance.

I am attaching a sample of the tracer schedule.


Contest entry: Daily goal setting worksheet

Next up we have an entry from Sandra J. Anaya, RN, with Tri-City Regional Medical Center. Sandra has sent in a daily goal setting work sheet (which we’ve posted below). Sandra writes:

We are a small facility trying to keep staff involved with JC preparedness, safety awareness, and providing continuous care. The attached tool is used for many purposes: determining a nurses knowledge of the patient, identifying any learning needs for a specific nurse or unit, keeping nurses involved with case management and discharge planning. The nurse is asked to present a “picture” of the patient by answering key questions much like a JC Surveyor would do. Other interdisciplinary team members participate. QM monitoring is included for labeling tubings, assessment of pain, etc.

The cumulative results are used as part of the PI program and reporting process as well as the competency program. Staff development is provided based on the needs identified. It takes no more than 15-20 minutes per nurse and nurses are randomly chosen each time rounds are made, which is 2-3 times per week per shift. Nursing Supervisors are responsible for conducting the rounds.

It has worked out well, particularly for new nurses who need guidance and direction. More importantly, nurses learn that their knowledge of patients is valuable to other departments and disciplines in coordinating care. It is an opportunity to update the plan of care and can serve as a team conference. We can review the chart for other things as well–signing of verbal orders, reporting of laboratory results to MDs, etc.


Contest entry: Mock codes

We  have several new entries today. The latest comes from Carolyn Weil, consultant, quality and clinical safety/risk management and regulatory compliance with St. John River District Hospital, East China, MI. She writes:

We’ve had great success with improving staff competence by conducting monthly mock codes. We are a 68-bed hospital, so resources are limited. The Nursing Educator indiscreetly places a mannequin with an attached cardiac simulator in an empty patient bed, radiology table, or any place a code situation could occur. We lure an associate into the room and present the patient’s clinical scenario. The associate initiates a “Code Blue” through an over-head page, just like the real thing. Associates assigned to the “code team” for the shift, Cardio-Pulmonary, Medical Staff, ACLS Nursing Anesthesia, and Laboratory all respond. The code progresses as the “patient’s” condition changes, as realistically as possible.

We measure the success of the mock code using 13 pre-determined criteria, such as 1 min or less from call to CPR, room set up with ambu and suction, is a lead running the code, etc. When we started doing mock codes our compliance to the 13 indicators was 45%; today our compliance is 92%. In the beginning, the associates were apprehensive and reluctant to participate. Today the associates are confident and eager to show off their skills.

Contest entry: Privacy week

Here’s our latest entry–a very timely one from Michael Neiman, senior director at Thomas Jefferson University Hospitals in Philadephia, PA. Michael writes:

Utilize Privacy week (April 12 – 18) to educate staff on requirements and standards related to privacy/confidentiality the week. Your compliance staff can assist in the preparation and educational activities so you can spread the work around.

Watch the yearly calendar for other “weeks” throughout the year to have other departments get the communications out to staff for accreditation.

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… 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!