Complying with state and federal regulations is critical for hospitals to receive funding, attract patients and most importantly, ensure safe, high-quality care. Mark Pelletier, RN, COO of accreditation and certification operations at The Joint Commission, and Tom Barton, RN, field director at The Joint Commission, share five hospital accreditation survey mistakes to avoid.
1. Lacking a safety culture. Failing to develop a culture of safety and quality is one of the biggest mistakes hospitals make because the culture forms the foundation of all activities, including those examined by surveyors. Without leadership support and staff engagement in a culture that focuses on safety and quality, hospitals are more likely to either be deficient in certain standards or meet the letter of the law without accepting the full meaning of the standard, which can ultimately jeopardize safety, according to Mr. Barton and Mr. Pelletier.
"Organizations we find that do really well are ones embracing quality and safety and not just doing [something] because the standard tells them to," Mr. Barton says.
2. Not being prepared. Being prepared and organized for an accreditation survey is critical to success. Mr. Barton suggests hospitals prepare by doing mock surveys to assess their compliance and to ease anxiety during the survey. Having the requisite documents on hand and organized will also ease the day-of survey process.
However, hospitals should not assess their compliance only for the surveys. The purpose of an accreditation survey is to ensure organizations provide safe, quality care. Therefore, hospitals should approach survey preparedness as a way to improve the organization rather than as a daunting task to complete every three years. "Organizations need to understand how each of the standards promotes quality and safety," Mr. Pelletier says. "They need to understand up front that the standards are designed to help improve quality and safety in the organization."
3. Failing to meet environment of care and life safety standards. Environment of care and life safety standards are some of the most common standards hospitals miss, according to The Joint Commission. In the first half of 2013, these categories accounted for three of the five most frequently unmet standards, and in 2012, they accounted for four of the top five. For example, in 2012, 51 percent of hospitals failed to meet LS.02.01.20: The hospital maintains the integrity of the means of egress. In the first half of 2013, 54 percent of hospitals missed this standard.
Another commonly missed requirement is sealing penetrations in fire and smoke barriers, in which hospitals fill holes in the fire wall with the correct material. Mr. Pelletier suggests developing policies and procedures for supervising contractors at the facility and ensuring penetrations are sealed when they make holes for cables, wires or other items. He also suggests leaders assess the environment of care when they do leadership rounds to discuss safety with staff.
4. Failing to maintain records. The number one standard hospitals missed in 2012 and the first half of 2013 is in the record of care, treatment and services category: RC.01.01.01, which states the hospital maintains complete and accurate medical records for each individual patient. The Joint Commission expects to see the rate of noncompliance diminish as hospitals migrate to electronic medical records.
5. Lacking a sufficient performance improvement plan. Performance improvement plans are important parts of accreditation surveys, as they tell surveyors how well a hospital identifies and corrects deficiencies. The Joint Commission monitors hospitals' progress on their plans annually and provides guidance to help hospitals improve.
Surveyors look at the integrity and completeness of the plan as well as hospitals' efforts in meeting their goals. In fact, hospitals' ability to identify weaknesses in their organization and implement strategies to rectify them is more important to surveyors than their ability to always meet their goals, according to Mr. Barton. Hospitals can access process improvement strategies from hospitals across the U.S. from The Joint Commission's Leading Practices Library and its Core Measure Solution Exchange.
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