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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Volume 1, Issue 2

Susan WisniewskiComplete Quality

By Susan Wisniewski, MPA, CPHQ - Manager, Accreditation and Regulatory Compliance

“Surprise, the Surveyors are here.” These are words we should be prepared to hear at any time since virtually all accreditation surveys are now unannounced. Hospitals, pharmacies, laboratories and medical services are more highly regulated and by more agencies. We must always be prepared. 

What are the benefits of accreditation, licensure and certification?Nursing Excellence
The Joint Commission is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. The California Department of Public Health (CDPH) licenses the Hospital based on an inspection of the facility. The license is maintained by staff providing services that meet their regulations. 

We are also surveyed and inspected by a variety of other agencies such as:

  • California Children’s Services (CCS)
  • Commission on Accreditation of Rehabilitation Facilities (CARF) – We have the only CARF accredited independent Rehabilitation Center in California
  • COLA (known only by this acronym) – Accredits our laboratory services
  • American Nurses Credentialing Center (ANCC) – Accredits the Magnet Program;
  • Children’s is among five percent of hospitals nationwide to achieve Magnet status

What agencies have surveyed the Hospital recently or are anticipated this year?

Surveys Conducted in 2009:

Surveys Anticipated in 2009:

  • Consolidated Accreditation and Licensing Surveys, including The Joint Commission and CDPH – expected by Aug. 30

Surveys Anticipated in 2010:

Why are these accreditations and certifications important?

It has been demonstrated that with accreditation or certification, hospitals document improved patient care while striving to exceed laws, regulations and standards. Our Hospital has shown increased organizational commitment to safety and quality. In addition, The Joint Commission survey substitutes for federal certification surveys (CMS) for Medicare and Medicaid reimbursement. These credentials also engender stronger community confidence in our services and our Hospital.

Remember, providing quality care + keeping children safe = ready for survey.

The accreditation process

Although many surveys are required for continued licensure or certification, The Joint Commission surveys the Hospital at our invitation. Accreditation is voluntary and the Surveyors are our guests. We request an accreditation survey to challenge us to maintain and improve an already strong commitment to high quality of care and patient safety.

The accreditation process focuses on how an organization integrates laws, regulations and standards into daily operations to deliver safe, high-quality care.  Fortunately no special preparation is required. Staff does not have to memorize regulations and standards since they have already been incorporated into many of our practices and policies. They must, however, understand how to effectively carry out their duties in a manner that meets the Hospital’s goals for consistent high-quality care. 

The primary method surveyors use is to trace patients’ path during their hospitalization. This process allows surveyors to evaluate our strengths and challenges, the integration of related processes, and the coordination and communication among all staff involved in the care of a patient.

What is the key to continual preparedness?

Communication: Regular communication is the best way to stay prepared.  Communication is essential in all directions – vertically, laterally, and across disciplines. Hospitals that are most successful with the survey process are those where senior leadership endorses the survey process, accepts the challenge of a survey visit and communicates to everyone the expectation of full commitment to the process.

Practice: The survey process has changed and surveyors no longer want to review manuals and talk with leadership. They spend more time talking directly to care providers and observing care. Children’s Hospital has a robust patient tracer program with leaders conducting six to eight tracers a month, on all shifts – including the night shift. These tracers prepare our staff for the “real” survey. In fact, this is our most effective approach to staff preparation. Teams identify issues – some can be fixed on the spot, while others require a hospital-wide approach to change. Being prepared for a survey is a shared responsibility and our success depends on every employee.

Complete QualityResources and consultation: Check the Complete Quality webpage on George, Children’s intranet, for survey questions, Joint Commission standards and links to CDPH and CMS. PowerPoint presentations and handouts from the educational series, Regulatory Essentials, are also available to help in identifying opportunities and to assist staff with learning the new and challenging standards. Leaders in specialty areas (Laboratory, Rehabilitation, and Pharmacy) can assist you with specialty specific questions and the Accreditation and Regulatory Compliance Department can help locate resources and complete research.

If you can articulate your role, effectively carry out your duties and provide Children’s standard of patient care, you’ll be ready when you hear “Surprise, the Surveyors are here.”


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