Examples of how Center for Healthcare Accreditation advisors have helped members
These are just a few ways in which institute members have benefited from their senior advisor. Whenever questions or challenges arise, we encourage you to reach out to your advisor.
Preparing for a successful Joint Commission survey when the organization has new programs
A senior advisor was contacted by a newly hired Director of Quality that had no experience with a hospital based Sleep Lab. The organization was in the infancy stage of establishing this new program. The senior advisor was able to assist with the process to ensure the new services would meet the required elements of performance prior to a Joint Commission Survey. The senior advisor was able to provide support with policy and form development, medical staff privileging processes, and staff education program development. The Center Client was also provided references of other Center Clients that had developed similar programs; facilitating an on-going dialog to share best practice as well as "do's and don'ts." The senior advisor scheduled a mock assessment of the new services and provided on-site guidance prior to a successful Joint Commission survey.
Auditing a process to improve compliance with an established procedure
At a hospital where surgeons were having difficulty reaching compliance with all of the elements required by the Joint Commission for a brief post operative note because they neglected to include estimated blood loss and/or specimens removed. The quality and accreditation readiness department along with the members of the medical executive committee were frustrated by multiple failed attempts to improve in this area of documentation.
When the Senior Advisor was informed of the problem, she recommended an audit be conducted in an attempt to determine if any trends were evident. Two issues quickly emerged from an in-depth look at this documentation problem. 1) The records failing to reach compliance were from procedures where there was typically minimal or no blood loss and there was no specimen removed. The senior advisor, knowing that physicians tend not to do things they think are meaningless, understood the root cause behind the lack of compliance. The surgeons weren’t writing something they considered obvious by the nature of the procedure! The solution? The senior advisor helped the hospital craft a brief post note template that included the requirements of the brief post operative note, however included this special wording for estimated blood loss and specimens removed:
- EBL: Minimal unless otherwise documented
- Specimen: None unless otherwise documented
A second audit determined 98% compliance in just over one month after the template was implemented.
Document Library | An excellent resource
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Question of the Month | Expert Advice & Guidance
- Are there specific requirements for governing board members, as leadership, to receive education related to the 2009 TJC standards?
Yes. Specifically under the 2009 standard LD.01.07.01, governing board members are to be oriented to the hospital's:
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