How to find methods to assess continual survey readiness in your facility

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PPR, staff encouragement are proven strategies

After reading this article, you will be able to:

Identify components and focus areas of a PPR plan

Discuss educational components that Northwestern Memorial Hospital implemented to encourage consistency

Finding a way to evaluate hospitals in preparation for the next unannounced survey can be a frustrating task. Proper use of PPRs and employee encouragement programs are two ways successful hospitals equip staff members to maintain survey readiness, and they are seeing results. Using a PPR program is a good way to get organized and shift staff perspective from preparing for a survey to a culture of continual compliance, Jodi Eisenberg, MHA, CPMSM, CPHQ, program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago, said during HCPro’s February 5 audioconference, “Survey Readiness: Strategies, Tools and Tips for Joint Compliance.”

“We organize the PPR in a focused way,” Eisenberg said. This allows for an opportunity to evaluate survey readiness across the hospital and the work process that is in place.

“We use it as an opportunity to access compliance but move the focus to excellence in relation to our mission, vision, and values,” she said. “We want more of a focus on excellence, not [just] compliance, and equipping our employees with the information they need to make that happen.”

Components and focus areas of this PPR plan include:

Practicing questions that The Joint Commission might ask the staff

Preparing a checklist and timeline of the items that must be accomplished and displaying this information where everyone can see it

Establishing a core group within the facility focusing on PPR with whom the staff can communicate

Comparing the results of different hospital departments to allow them to learn from each other

This PPR plan gives Eisenberg and her staff a unified vision.

“We want to give our staff knowledge so they know the why behind the rules,” said Eisenberg. “Take rules and regulations down to the level of education, communicate, and integrate the whys. It encourages employees to stay in compliance.”

Encouraging consistency

Northwestern encourages consistent compliance through flexibility and communication within all departments, as well as staff education. Adjusting the content and delivery of this staff education to fit each department has proved useful to staff members. Educational developments the hospital has taken on include:

Color-coded charts describing what the facility is doing well and what needs improvement

Monday morning messages handed out to each department

Quizzes for staff members

Bringing in outside observers to give an objective voice

Accountability partners to encourage positive relationships

Using leadership to maintain compliance

Lisa Kulp, accreditation specialist with the Grant Medical Center of Ohio Health in Columbus, concurred with Eisenberg during the audioconference, but stressed that “it takes leadership for employees to be a success.” With patient safety a high priority, Kulp recommended the following methods, already used successfully at Grant, to educate staff members about continual compliance:

Brief one-page summaries sent out with paychecks that discuss the facility’s performance in terms of compliance

Daily “huddles” for information sharing

Weekly fax blasts throughout the facility with up-to-date information on compliance

Peer coaching within departments

Patient safety coaches

Staff recognition through awards

Kulp sees the power of staff recognition and awards as motivation for the hospital as a whole. Through peer coaching and positive accountability, Grant is able to showcase leadership within its staff.

The results are “commitment, understanding, and compliance,” said Kulp.

Kulp and Eisenberg see hospitalwide communication as one of the best tools in education.

“Sharing information to help in all areas benefits everyone,” said Eisenberg. “Nursing shares with [physical therapy], and [physical therapy] shares with pharmacy.”

This system, she said, not only lends for continued compliance but also to a great hospital dynamic.

Editor’s note: Visit to find a full version of “Survey Readiness: Strategies, Tools and Tips for Joint Compliance,” available online through HCPro’s Audio Archives feature.