Joint Commission survey readiness team praised Last Updated: February 17, 2015
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CHALLENGE

Joint Commission survey readiness is a constant need for all hospitals. Emerson Hospital in Concord, MA, like so many healthcare organizations today, must deal with a long list of competing priorities with fewer resources than in past years. With its triennial Joint Commission survey expected in the last quarter of 2013, Emerson Hospital’s leadership decided it needed additional support to ensure a successful survey experience.

SOLUTION

Premier’s Regulatory Readiness Advisory Services team was standing by ready to help. Emerson engaged the team to conduct a series of four mock Joint Commission surveys to test Joint Commission survey readiness. The first began in January, 2013, and as expected, it identified a number of improvement opportunities. Premier’s team jumped in to help the Massachusetts hospital’s leaders develop and implement an accelerated corrective action plan. During the next nine months, Premier’s Regulatory Readiness Advisory Services team conducted a series of three additional mock surveys to help Emerson Hospital prepare successfully for its accreditation survey later in the year.

Recognizing the positive impact of continuous Joint Commission survey readiness support, the hospital in fall 2013 joined the Premier Accreditation Readiness Network to access on-going web-based training as well as networking and feedback from peers as well as readiness resources not otherwise available to the organization. The network is a group of some 30 hospitals that support each other in continuous accreditation survey readiness.

Other advantages include getting to know the Joint Commission survey team leader before the triennial survey through a calendar-year introductory conference that targets survey changes and focus areas. The network also provides access to survey activities and “leading practices” through the PremierConnect™ user-friendly community social networking site as well as real-time access to remote support from Premier experts for standards clarification, interpretation and readiness assistance.

RESULT

The Joint Commission conducted a full triennial survey at Emerson in November 2013. The final Joint Commission report was stellar with only four direct impact findings and 16 indirect findings – a reduction of more than 75 percent in total noncompliant standards compared to the first mock survey conducted by Premier 10 months earlier. Corrective action plans, on-sight and remote support and coaching by Premier’s team helped Emerson reduce non-compliance by 100 percent in situational decision rules and 75 percent in direct impact while maintaining current levels with indirect impact standards.

Emerson’s Lesley Fucci, senior director of Quality and Patient Safety, and Liz Curran, accreditation coordinator, shared their positive experience with the accreditation readiness support at the 2014 Premier Annual Breakthroughs Conference and Exposition in June in San Antonio, TX.