Staying Survey Ready
“We always try to stay survey ready,” says Pilant. “Even during years when we aren’t being surveyed. It’s a continuous process.” Staying survey ready means circulating information about new standards across the organization, reviewing the Joint Commission standards manual section by section throughout the year, and implementing innovative programs that help keep patient safety top of mind, including:
- The Speak Up program, a Joint Commission recommendation, in which everyone is encouraged to report problems or near misses, without any stigma or blame attached.
- Environment of Care Rounds in which multidisciplinary teams perform unscheduled rounds in a collaborative and nonthreatening way in order to “look under the hood” and see what’s going on in each department.
- Unit Practice Councils, where staff learn from the bedside what works and what doesn’t when it comes to improving hand-offs and preventing falls.
- Daily Safety Huddles in which managers meet and go over any safety concerns from the last 24 hours, fostering a blame-free atmosphere and asking: How can we change our processes so staff is supported and patients are safer?
An Educational Survey Experience
The survey experience itself only added to Roane Medical Center’s enthusiasm for its culture of safety. “We had three Joint Commission surveyors. They all brought different perspectives, were very collegial, and helped educate our staff,” says Patty Ashley, Senior Regulatory/Risk Manager. In one instance, the pharmacy staff was a bit anxious beforehand, but the surveyor calmed their fears immediately, talking about his own experience and his passion for sterile compounding. “The conversation just took the anxiety right out of the air,” says Ryan Reddick, Pharmacy Director. When the laboratory was being surveyed, the surveyor specifically asked to have as many lab staff as possible join her for lunch. During that time she shared information and videos, talked about zero harm and how harm could reach a patient. “It meant a lot to the lab staff that she took her own time to do that,” says Ashley.
Measuring Success by the Numbers
As far as assessing the success and value of accreditation, “You can’t manage what you can’t measure,” says Pilant. Here are a few statistics that show Roane Medical Center’s safety mindset successes:
- No catheter-associated urinary tract infections in 6years
- Only 1 central line bloodstream infection in 6 years
- Only 1 pressure injury in 2019
- Only 1 c.diff infection in 2019
These are the result of a systemwide emphasis on putting patients first – as well as Roane Medical Center’s drive to reach zero harm. “We really embrace The Joint Commission’s mission to make healthcare a high reliability industry,” says Ashley. “The Joint Commission is the starting point for looking at all our programs and procedures. They make us think deeper and broader about the latest issues like opioid stewardship, ligature risks, and patient identifiers.” Roane Medical Center also tackles issues head-on. One example was the instance of stock-outs. They asked themselves, how can we decrease the number of times a nurse comes to a pharmaceuticals cabinet and it’s out of what she needs? Through a multidisciplinary approach, open communications between pharmacy and nursing, and by studying the times of day and locations of medication use, they were able to reduce stock-outs from 250 per month to 40 per month.
Roane Medical Center also engages with their medical staff and shares quality numbers with them, so physicians have the opportunity to ask questions about the data. “Doctors love to talk about the data,” says Pilant. “And when we talk about patient safety goals, we don’t just talk numbers, we talk about what this means to patients, which makes it a lot easier for a person to understand and support.”