Journal of Nursing Administration:
Departments: Spotlight on Leadership
Baas, Donna MA, RN; Bryant, Keneshia PhD, RN, APN, FNP-BC; Sadaka, Heba MSN, RN, CNE; Henderson, Tamisha MSN, RN, MHA, CCM
Author Affiliations: Director of Accreditation and Regulatory Compliance (Ms Baas), Medical Center; Assistant Professor (Dr Bryant), Clinical Assistant Professor (Ms Sadaka), and Clinical Instructor (Ms Henderson), College of Nursing, University of Arkansas for Medical Sciences, Little Rock.
The authors declare no conflicts of interest.
Correspondence: Dr Bryant, University of Arkansas for Medical Sciences-College of Nursing, 4301 West Markham St, Slot 529, Little Rock, AR 72205 (email@example.com).
A partnership between an academic medical center and a college of nursing has proven to be an equally beneficial opportunity for continuous readiness for The Joint Commission. Nursing students learn the principles of regulatory compliance and accreditation through simulated surveys in their leadership and management course. The medical center receives continuous feedback and achieves survey readiness and fluency with better-prepared new graduates.
Academic medical centers are faced with the ongoing demands of preparing the future workforce while maintaining standards of excellence in patient care. Educating and training future nurses with the skills required to meet the standards of The Joint Commission (TJC), as a leading regulatory agency, can be a challenge. Academic medical centers are in a unique position to provide high-quality care and collaborative education through partnerships with affiliated educational programs. Often, nursing students are thought of as the sole beneficiaries in educational relationships with a medical center, in part because of the traditional nature of practicum and clinical experiences. Targeted educational opportunities can be mutually beneficial for medical centers and colleges of nursing, as well as the students they serve.
A key component of the TJC accreditation process for hospitals is the conduct of a triannual survey.1 Because of the nature of the unannounced surveys, it is essential that the organization build and sustain a level of performance that represents continuous survey readiness.1 Although this level of compliance is essential, continuous readiness also requires a performance mindset that creates an organizational culture of high quality and safe patient care and recognition of the standards. Success requires engagement at all levels of the organization, including new graduate nurses.
Description of the Project
During the fall of 2010, the University of Arkansas for Medical Sciences (UAMS) College of Nursing (CON) and the UAMS Medical Center identified an opportunity to simulate a TJC survey with nursing students that would augment the undergraduate leadership and management course in the CON. The goal was to introduce senior nursing students to the principles of TJC compliance and accreditation and promote readiness in the medical center. Faculty designed a simulated survey experience based on TJC standards and readiness tools.2 Several of the most highly recommended readiness tools include tracers and mock surveys.3 Tracers provide a method to comprehensively evaluate compliance with TJC standards. This interactive activity takes the reviewer to various departments to review the environment of care, interview staff, and observe documentation in the medical record by following the flow of a patient.3 Variances or findings are documented and analyzed for both broad and focused quality improvement opportunities. Mock surveys incorporate this tracer method in a 5-day simulated survey that replicates the components of an actual TJC survey. This exercise provides an excellent format for teaching and practice so that when the unannounced surveyors actually arrive, the organization is prepared. Although these tools are invaluable, it was also important to continuously seek new ways to engage staff and creatively build survey readiness; therefore, nursing student involvement provided this opportunity. In coordination with medical center accreditation leadership and CON faculty, the new coursework included a review of TJC standards and tracer methodology, as well as a clinical experience that allows students to conduct surveys on various medical center units after the simulation experience. The students, working with a hospital regulatory preceptor, functioned as the lead surveyor and conducted the tracer. The survey requires students to locate policies, procedures, and other records; observe employee behaviors; review patient charts; interview staff and patients; and inspect nursing care units in accordance with the standards they were monitoring.
Since the inception of the program several years ago, representatives from the medical center accreditation leadership team and CON faculty have continued to collaborate to consider lessons learned from previous surveys and student simulated survey activities. Currently, this teaching strategy has evolved to a 2-hour presentation from medical center leadership and CON faculty about the mission and functions of TJC, the standards and components of the TJC survey, and an overview of the survey tool to conduct a tracer. Following this, students are divided into small clinical groups and report to their assigned nursing unit to take on the role of student “surveyor.” Students are generally on their assigned unit for approximately 2 to 3 hours to complete the survey. At the conclusion of the survey, students compile and review the data and develop a formal PowerPoint presentation with evidence-based plans for corrective action to present to CON faculty, the medical center’s nursing administrators, and fellow classmates. The students are required to be familiar with current national patient safety goals4 and plan their survey accordingly. These goals are directly related to the mock survey outcomes that are the focus of the tracer. The students’ understanding of the patient safety goals puts them at an advantage in looking for specifics on the unit while using guidelines outlined on the survey. The students are encouraged to make an informational handout for staff to support the recommended practice for compliance. Although this is not a requirement, most students presented the handout to the staff and managers as a brief overview of the results of their survey.
In an effort to promote performance improvement and engagement between the nursing students and staff nurses and to increase staff nurses’ awareness of deficiencies on the survey, the student assignment for the class has been continually revised. As part of their class assignment, students are now required to provide an overview of the simulated survey results and create poster displays to educate staff nurses about the areas of improvement and corrective actions needed to improve patient safety and meet other standards of TJC on the specific nursing units. After the class assignment is complete, each group of students meets with the staff and unit manager to present their findings, along with a poster display. Students are required to use at least 2 research-based or current (within the last 5 years) journal articles to support their recommendations for improvement and incorporate these sources into their presentation.
Copies of the simulated survey results are given to the nurse managers of the various medical center units. This information can then be used to identify trends and areas requiring improvement, in addition to comparison with medical center mock survey results. Over the past few years, the student survey findings have been closely correlated with medical center mock survey outcomes and the medical center triennial survey. Similarities found between the student and leadership tracers included important findings in medication management, infection control (ie, hand washing), environment of care, performance improvement, patient rights, patient care, life safety, and leadership. Variances were identified by compliance leadership as special focus areas and received more intense review and education. The student simulated survey tool is reviewed by the medical center administration at least annually to verify its consistency with current TJC standards and requirements.
Benefits of the Project
The incorporation of TJC principles into the curriculum of generic nursing students provides benefits not only for the students but also for their future employers. This ongoing project effectively introduces nursing students to the TJC survey process and fosters engagement in compliance and quality in the hospital setting as students make the transition to staff nurse positions. The UAMS Medical Center hired a total of 75 new graduates from the UAMS-CON baccalaureate program in 2011(n = 30) and 2012 (n = 45). All of these new graduates participated in the simulated survey. As new employees, they have been able to bring their perspective from their recent interactive experience to the patient care settings. This new understanding has shortened the length of time needed to provide regulatory information in orientation and has created a new cadre of regulatory champions on the units.
Conclusions and Implications for Nurse Leaders
The benefits of TJC simulation project are numerous, including (1) collaboration between medical center leadership and CON faculty, (2) TJC standards preparation of the future nursing workforce, (3) continuous preparedness and regulatory readiness among nursing staff, and (4) readiness and regulatory feedback for medical center administrators from multiple aspects. In the simulated survey experience, each student takes on the role as surveyor and learns how to identify outliers to standards and procedures and consider appropriate corrective action. The medical center receives ongoing feedback on compliance levels of TJC standards. In addition to this feedback, students provide the nursing staff ongoing education and recommendations to meet the TJC standards and to improve the quality of patient care.
2. Bryant K, Hambuchen J, Brown J, Bell A, Martin-Watson A, Rainey L. Nursing students as Joint Commission surveyors. Nurse Educ. 2012; 37 (1): 8–9.
3. Murphy-Knoll L. Nurses and the Joint Commission tracer methodology. J Nurs Care Qual. 2006; 21 (1): 5–7.