Turning Joint Commission survey preparation into a treat

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Turning Joint Commission survey preparation into a treat


One of the ongoing challenges for Joint Commission survey coordinators is also one of the most simple to put ­into words: How do we put Joint Commission educational materials into the hands of our staff?

Sometimes the trick is to turn survey preparation and accreditation education into something fun, rather than simply something required. As the old saying goes, "You can catch more flies with honey than vinegar," or in the case of Ministry Saint Michael's Hospital in ­Stevens Point, WI, you can connect with more staff with ice cream. The hospital has had great success by turning a simple concept-essentially an ice-cream social-into an opportunity to reach staff on all levels to provide education on Joint Commission compliance.

The trick, as accreditation manager Anne Radtke ­explains, is how the information is distributed.

Radtke and her Joint Commission team members arranged a large conference room into booths with tables on which the various components of the ice-cream sundaes were distributed. It sounds simple enough, right?

But in order to build the complete sundae, staff members had to answer questions about specific chapters of The Joint Commission's requirements. That's right-from the get-go, staff were faced with Medication Management chapter questions before they could pick up their bowl and head for the next table that held the ice cream.

"The tables were set up by chapter," says Radtke. "We had two nonclinical and two clinical questions at each table, and we tried to get both types of staff to come to the event."

Staff wound their way through the tables, adding ice cream and toppings, before being faced with a final challenge. If they wanted a spoon to eat their ice cream with, they had to go to the last table and answer a final question. One year this question was about hand hygiene. Radtke and her team had set up a black light for demonstrating successful hand washing, and staff had to pass this final test to get their spoon.

Previous years were nearly as challenging, requiring staff to answer questions on the Environment of Care chapter-specifically, how to locate the emergency management plan.

"The whole thing was light-hearted, though," says Radtke. "There was no gotcha-we wanted to keep it fun."


The setup

It began simply enough, as a search for ideas for outreach and education. Radtke came across a similar story online and approached administration about the idea.

While it is a straightforward concept, there is a great deal of planning and work that goes into the development stages. Radtke notes that all Joint Commission team members need to be involved, and it is best to spell out all of your goals for the event at the very beginning.

"It's a lot of preparation up front," she says. "Our nutrition services had great ideas and provided us with coolers, paper hats, and aprons, for example."

There are budgetary considerations as well, from time to the actual costs of the food and promotional signs, so some forethought is recommended.

"The staff reaction was great-they thought it was a fun way to learn about The Joint Commission," says Radtke. "It was non-threatening." Joint Commission team members volunteered and even agreed to dress up in ice-cream parlor attire.

The questions came from various sources, including the organization's own tracer tools. It specifically wanted to target the style of question a Joint Commission ­surveyor might ask, and also kept an eye on hot topics such as National Patient Safety Goals requirements.

Beyond that, there was also information like assessment tools for departments, the questions and answers from the event, a Joint Commission reference guide, and survey prep tips for staff to take along with them.

In terms of attendance, the 300-staff-member turnout speaks strongly to the event's popularity.


Outreach to clinics

The organization did have one hurdle in its attempt to reach all staff-there are more than 10 off-site locations beyond the main facility that Radtke's team wanted to include in the educational outreach.

"We're provider-based and have off-site clinic locations," she says. "They are also Joint Commission surveyed, and this was a great opportunity to bring everyone together."

In fact, the first time the ice-cream event was held, it coincided with the first time clinics were included in the organization's Joint Commission surveys, so the timing could not have been better. The organization also got a chance to look for ways to better ­integrate hospital and clinic survey preparation.

For the event itself, Radtke went on the road, visiting all of the off-site locations to make sure that she, as the accreditation manager, was able to personally connect with them.

Taking the event on the road had some limits, mostly in terms of cleanup. Rather than holding a full-scale ice-cream social, gift cards to a local restaurant that specialized in ice-cream desserts were given away if staff answered the questions correctly at the very end.

"It was nothing extravagant, but it was fun," says Radtke.

The program has been so successful that in anticipation of the organization's next survey, Radtke would like to plan the event again. The hospital expects a Joint Commission survey within the next year.