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Ready or Not … Here They Come!
How prepared is your institution for an unannounced visit from the Joint Commission?
When the Joint Commission issued its statement that all accreditation surveys would be unannounced, a shift occurred in the way hospitals had to prepare. Joint Commission President and CEO Dennis O'Leary stated that the idea arose out of popular demand from hospitals, with the goal being that every hospital is "in compliance with 100 percent of the standards, 100 percent of the time." Hospitals must now be prepared for inspectors any time from 18 to 39 months following the previous survey.
Hospitals cannot afford to "cram for the test" as in previous years. "In the past,we would gear up in preparation for the scheduled survey," recalls Diane Thorgrimson, Director, Patient Services Administration at Children's National Medical Center, Washington DC. "Now,we expect our team to be ready every morning for an inspector to walk in the door."
Most of the Joint Commission survey focus is on the clinical areas of the hospital. But for non-clinical departments, the spot inspection can be just as demanding. This is especially true for support services vendors, whose survival at the hospital depends on providing nothing but the best service at all times. A diligent approach to understanding and enforcing standards is vital to our success. Crothall recognizes that even a small violation by a member of our team can lead to big problems for the hospital.
What We Do Impacts Outcomes
Vendor responsibilities are often complex, especially when multiple departments are managed.
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Environmental Services is closely monitored for Infection Control violations. Employees must demonstrate behavioral competency in all stages of the cleaning process, storage of chemicals, and safety procedures.
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Facilities Management often has wider, cross-departmental oversight and responsibility for documentation of Environment of Care protocols.
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Laundry Providers must consider continuity plans to maintain linen availability in a disaster.
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Patient Transportation needs to consider not only Joint Commission standards, but also National Patient Safety goals, which have implications on proper communication and protocols for patient "hand offs" to prevent disease transmittance.
In the new survey process, the National Fire Protection Association's Life Safety Code takes on more importance. Because of this there are two major areas that Crothall must pay special attention to with respect to Life Safety. Failure to properly handle either one can result in immediate "conditional accreditation" status for the entire hospital. They are:
Statement of Conditions, which is an overall evaluation of Life Safety compliance. This is often the responsibility of the Facilities Director, who must fix any problems, big or small, and create a comprehensive plan for remedying larger violations. If the documentation is not maintained or the plan is not followed, this is considered a "busted plan."
Interim Life Safety Measures provide temporary safety guidelines to be used until major compliance issues are resolved. Failure in these areas triggers conditional accreditation, which can lead ultimately to a denial of accreditation.
Survey-Ready, Every Day!
How does Crothall Services Group view the Joint Commission challenge? According to President and CEO, Bobby Kutteh, "It is an opportunity for us to differentiate our company from the rest of the pack. We promise our clients the highest quality service and consistent delivery, and our success with spot-inspections proves that we deliver on that promise. In fact, we've been saying that we're 'Survey-ready, every day' for years. Now, that claim is being confirmed by the inspectors when they come through." Crothall is putting its money where its mouth is.
Recognizing a need for expertise in Joint Commission preparedness,we made the decision to work with an outside consultant. Mark Shamash, President of Safety and Disaster Solutions, Inc. (SDSi) has aided Crothall in evaluating and making recommendations to improve adherence to standards in several Crothall accounts."This is an opportunity we have not seen before," Diane Thorgrimson explains,"While we expect our vendors to be proactive, Crothall is definitely going above and beyond."
Accountability in Action
Crothall's track record so far is unblemished. After the Joint Commission unannounced surveys at over 70 client hospitals, Crothall has not been responsible for a single Requirement for Improvement (RFI) in any of the departments it manages. During a recent survey, Environmental Services was singled out for its thorough training documentation, which was simply a byproduct of Crothall's regular weekly "safety minders" program.
In another case, a Crothall employee was taken aside by a surveyor and drilled on cleaning protocols. Although the employee was nervous, she performed marvelously by simply remembering her basic Crothall training. That's the idea. With a sharp focus on standards and a commitment to ongoing employee training,we are helping hospitals be "Survey-ready, every day!"
“Crothall is the first support services vendor to use an outside consultant to verify its performance. Crothall is willing to move beyond operational considerations and take the blinders off to find problems before an inspection occurs, and do what is necessary to fix them.”
— Mark Shamash,
President, Safety and
Disaster Solutions, Inc.