Department: Leadership Q&A
Q We're due for an unannounced Joint Commission survey and my staff members are struggling with the tracer activity and survey preparation. Can you provide some easy readiness tips that I can use?
Normally, the initial response from staff when you mention The Joint Commission is “I hope I'm not working the day they come.” As a leader, you need to communicate to staff the importance of understanding that the survey is actually a real-time assessment of how the organization effectively and safely manages the care of patients and families. Engage your staff from the beginning and utilize your internal resources to assist you with staff preparation.
First, start with the basics. Spend a week with staff to assess if the unit is compliant with crash cart checks, refrigerator temperature logs, separating clean and dirty equipment, keeping hallways free of clutter, cleanliness, hand hygiene, and personal protective equipment. Next, I would recommend you start with assessing the current knowledge base of your staff members regarding the following:
- Are they familiar with The Joint Commission's National Patient Safety Goals and what your organization is doing to address these goals?
- Do they know what performance improvement efforts are being done in your department to improve quality, safety, and patient care?
- Are they familiar with The Joint Commission standards that apply to their job and department?
- Do they understand the organization's policies and procedures for fire, disaster, infection control, various code alerts, occurrence reporting, medication errors, adverse drug events, patient assessment and reassessment, restraints, care plans, advance directives, and suicide risk and domestic violence screening?
- Can they review a chart accurately for the following?
- —Is the assessment complete?
- —Is there a documented care plan?
- —Is the entry dated, timed, authenticated, and legible?
- —Are there unapproved abbreviations in the documentation?
- —Is pain assessed and reassessed at the required intervals?
- —Is the status of the patient's advance directive documented?
- —Are restraints in accordance with your organization's policies?
- —Is handoff/transfer documentation present?
- —Was suicide screening completed?
6. Do they understand what a tracer is?
When you explain tracer methodology, keep it simple. For example, tracer methodology is The Joint Commission's process of tracing the care of patients throughout their stay. Surveyors utilize tracer activities to assess patient care and system process issues for standard compliance. Tracer activities are also used to assess interdisciplinary relationships and communication between all departments or services.
It's important to utilize the trends of tracer activity to improve processes. Always communicate to staff about the ongoing improvements demonstrating compliance with The Joint Commission standards. Finally, to maintain the gain, emphasize to staff that the changes made based on the outcomes of tracer activity and department audits will be continued after the survey is over. Preparing for a Joint Commission survey is a lot of work, but staff members will be proud when they realize their hard work is affirmed by an accrediting body.