The Science Journal of the American Association for Respiratory Care

2008 OPEN FORUM Abstracts

FIVE SUCCESSFUL SYSTEMS TO MAINTAIN ONGOING MULITI-SITE READINESS FOR THE JOINT COMMISSION REVIEW

Carol Mihailuk1, Richard Ford1, Ted Vallejos1



Objective: The RC Department at UCSD Medical Center provides service at two hospital sites in the city of San Diego. Preparing 110 employees across two sites for an unannounced visit is a challenge that requires teamwork and innovation. We developed several systems to prepare staff to insure they understood policies and were able to dialog with surveyors regarding any standard applicable to Respiratory Services.

Methods:

  1. A day long annual department "Skills Fair" which all staff were required to attend, this included key topics such as safety goals, medication management, and "do not use abbreviations". A part of the Skills Fair included a fun, interactive game of answers and questions concerning all aspects of TJC review called "TJC Jeopardy".
  2. There were monthly e-mails sent out titled "Quiz of the Month", which kept staff updated on departmental and hospital wide initiatives.
  3. Frequent multi-discipline mock survey tracers were done with feedback on areas of concern.
  4. Job Cards were created for the RCP's that described their specific role; these were available on our web site for quick reference.
The cards included: visual check in patient care areas to ensure that they were free of equipment in the halls, patient medications were properly stored, patient orders and care plans were updated. A check on the oxygen tank storage to ensure that the limit of twelve oxygen tanks were in compliance. 5) RT Website was configured to capture important data regarding patient assessment, safety, patient education, and compliance with the ventilator bundle for VAP reduction.

Results: When the surveyors arrived unannounced in November of 2007, the staff was well prepared. The TJC readiness systems that were put in place adequately equipped staff for the actual review process. The RCP's involved with the TJC tracers verbalized the multidisciplinary process with ease thus evoking compliments from the surveyors regarding respiratory therapy's involvement in the patient care process.

Conclusion: TJC readiness was an every day practice in the RT department at UCSDMC. Keeping staff involved in the process assisted in decreasing the anxiety levels of the RCP. The mock surveys assisted in staff preparation of what to expect from a tracer review and what their role would be in the multidisciplinary team. Our staff performed well during the TJC review with the medical center receiving unconditional accreditation and no formal recommendations for Respiratory Services.