T
o ensure safe patient care, organization leaders must be continuously committed to fostering an environment
that encourages, supports, and requires safe and reliable care.1 Accreditation, patient safety, and quality improvement professionals have an important role to play in these efforts, often becoming the “voice” of patient safety and quality in their organization. Amid the din of competing priorities, budgetary pressures, hard-dying bad habits, and time
constraints, these professionals work hard to ensure that voice is heard.
Often, these professionals are the ones who must remind and educate leaders and medical staff about the urgency of patient safety and the structures that support it, including compliance with accreditation standards. They may also
be called upon to make these stakeholders aware of patient
safety or noncompliance issues that have been identified in
(continued on page 8)
Without the support of hospital leaders, hospitalwide changes
and improvement initiatives are difficult to achieve.
Accreditation Management Skills “
(continued from page 1) Communication is key.
Accreditation professionals
their organizations. Learning strategies for communicating with leaders and medical staff about these issues is an essential skill for professionals whose responsibilities include accreditation.
Patient Safety Systems
Effective January 1, 2015, The Joint Commission included in its Comprehensive Accreditation Manual for Hospitals a new chapter titled, “Patient Safety Systems.” The “Patient Safety Systems” chapter provides a framework, rooted in Joint Commission standards, upon which hospitals can build their integrated patient safety system—in which staff and leaders work together to eliminate complacency, promote collective mindfulness, treat each other with respect and compassion, and learn from patient safety events.2 In short, the chapter brings patient safety front and center and makes the connection between accreditation compliance and patient safety.
“Without support from leadership, effective, lasting change cannot occur,” says Laurel McCourt, MD, consultant, Joint Commission Resources. “The initial strategy should be to familiarize your leadership with the ‘Patient Safety Systems’ chapter and the ‘Leadership’ chapter. That will be the expectation of the survey team.”
As the chapter states, “The ultimate purpose of The Joint Commission’s accreditation process is to enhance quality of care and patient safety. Each requirement or standard, the survey process, the Sentinel Event Policy, and other Joint Commission initiatives are designed to help organizations reduce variation, reduce risk, and improve quality. Hospitals should have an integrated approach to patient safety so that high levels of safe patient care can be provided for every patient in every care setting and service.”1 Accreditation professionals can use the content of this chapter to help make the case to key stakeholders (including leaders and medical staff) for accreditation, performance improvement initiatives, and patient safety.
Strategies for Encouraging Leadership Engagement
Communication is key. Accreditation professionals can access or even create a variety of channels for
communicating with leaders about accreditation and patient safety issues. For example, Norma Kay Sprayberry, RN, MSN, CJCP, consultant, Joint Commission Resources, recommends developing a formal plan for continuous survey readiness/continuous compliance to quality and safety. “Engaging senior leaders in an organizational strategy
for ongoing compliance is an effective means of fostering
can access or even create a variety of channels for communicating with leaders about accreditation and
patient safety issues. ”
leadership involvement,” Sprayberry says. Sharing your plan with senior leaders, obtaining their input and buy-in, can help put the issue front-and-center on a leader’s desk.
“Involving leaders in the development process can help gain their buy-in and cement their commitment to implementing the strategies.” (See figure 1 on page 9)
.jointcommission.org/facts_about_the_intracycle
_monitoring_process/ for more information on ICM and FSA.) “It will be helpful to utilize the FSA/ICM process to prioritize issues in the organization from an accreditation manager’s perspective to present to the leadership,” McCourt says. “When presenting an issue that will require funding from leadership to be in compliance, a good approach to resistance is to ask the question, ‘If a serious patient safety event, such as a child abduction or patient suicide happened today, what would we change?’”
Sprayberry advises that mock tracers provide an opportunity for leaders to see firsthand the impact that accreditation compliance has on patient safety and the quality of care. “Encourage and facilitate leader participation in tracer activities,” Sprayberry says. “Let them see how
the process works as well as the results.” Another effective strategy is to meet regularly with leaders, including the CEO, to update them on the current state of compliance and identify opportunities for them to become involved in addressing organizational barriers to compliance.
Accreditation and patient safety staff may also consider facilitating an “Adopt a Unit” program, Sprayberry says, in which a senior leader provides a more comprehensive level of support and oversight to a specific clinical area. Leaders visit the unit/department more frequently making rounds, talking with staff to assess staff concerns, which helps to drive a culture of safety. When staff develop the trust to share concerns, leaders make improvements on those concerns
and communicate those improvements to those staff. This encourages “learning from the front” and helps leaders to understand the unit’s needs.
© Copyright, Joint Commission Resources
Getting Medical Staff on Board
An effective system functions best when all stakeholders are active and engaged. Thus, medical staff buy-in is essential to achieving continuous compliance with quality and safety standards, to maintaining continuous survey readiness, and
to building a strong patient safety system. Without physician engagement, safety improvement efforts will be flawed in their design, have trouble getting off the ground, and/or have difficulty being sustained. Physicians have a huge impact on the quality of care delivered, clinical variation, and resource consumption, not only in their own practices but across the continuum of care experienced by patients.1
“The expectation is that the medical staff be a part of
accreditation-related activities can have a tremendous impact on the success of the organization’s efforts, according to Sprayberry. She advises that such a committee would meet monthly for no longer than one hour. In addition, “as with leadership, encourage medical staff involvement in tracer activities,” she says. Take medical staff leaders with you to conduct tracers of medical staff responsibilities, such as anesthesia assessments or implementation of the Universal Protocol. “Providing reports on tracer results at meetings of medical executives can also help keep these issues front and center, especially when the results relate to physicians or quality and safety issues.” TS
the solution and that they lead performance improvement,”
McCourt explains. “It is imperative to develop physician champions for performance improvement projects. This does not always have to be a senior leader. Find a doctor who is truly interested and passionate about a given project in a given department.”
Forming an organization steering committee that includes physicians, medical staff leaders, senior leaders and accreditation staff, to provide oversight for compliance to
References
The Joint Commission. Patient Safety Systems chapter. Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: Joint Commission Resources, 2015.
The Joint Commission. Patient Safety Essentials for Health Care, 5th ed. Oak Brook, IL: Joint Commission Resources, 2009.