Safety Survey Readiness for Joint Commission Meeting
A call to action for Joint Commission safety survey readiness with a focus on identifying and mitigating patient and provider safety risks. Highlights include known risks from the 2021 survey findings, Vizient mock survey findings, and the purpose of the upcoming survey to ensure patient and provider safety. The importance of preparation, leadership, and adherence to standards is emphasized for a successful triennial survey before September 1, 2024.
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Joint Commission Safety Survey Readiness Leaders Meeting January 3, 2024
A Call to Action: A Call to Action: Joint Commission Safety Joint Commission Safety S Survey window is open! urvey window is open! Our triennial survey must take place before Sept 1, 2024 Now is the time to prepare When we re survey ready, we re patient ready We have many new leaders and many new team members, and we need a readiness system that supports our teams We need local leaders to know and own know and own both risks and risk mitigation in their areas, according to institutional standards/policies Thank you for your time - your leadership matters!
Purpose of the Survey: Purpose of the Survey: To Identify and Mitigate Patient and Provider Safety Risk To Identify and Mitigate Patient and Provider Safety Risk Known Risks: 2021 JC Survey Findings Up-to-Date Action Plans and Performance Data are Required Recent survey activity from other organizations Internal gap analysis of JC focus areas and new standards Results of our recent mock survey Ongoing efforts to find and mitigate risk Internal rounding program: Tuesdays Before Two Daily Management System/Be Safe Huddles
Joint Commission 2021 Survey Findings Joint Commission 2021 Survey Findings Behavioral Health - Suicide Prevention Instrument Integrity Scope Processing and Storage Adherence to Manufacturer s Instructions for Use Designated Rooms with Proper Ventilation and Airflow Hand Hygiene and Surgical Attire
Vizient Mock Survey Findings Vizient Mock Survey Findings - - October 2023 October 2023 Foundational Infection Control practices Foundational Infection Control practices Hand Hygiene Surgical Attire and PPE Use Separation of Clean and Dirty Environmental Cleanliness Eyewash Eyewash Station Access in an Emergency Access in an Emergency Station - - Required Weekly Checks, Required Weekly Checks, Behavioral Health Behavioral Health Documentation of 1:1 Observation Oversight of Suicide Risk and Prevention Strategies High Risk Device Infection Control High Risk Device Infection Control Reprocessing Following IFUs Glucometer Safety Specific to Bioburden and Dust on Devices Tracking of Devices by Patient Environment/Life Safety Environment/Life Safety Temperature and Humidity in OR and SPD Use of Extension Cords and Unapproved Relocatable Power Taps (Power Strips) Door Propping
Vizient Vizient Mock Survey (SAFER) Matrix Mock Survey (SAFER) Matrix IMMEDIATE THREAT TO LIFE IMMEDIATE THREAT TO LIFE IC.01.02.01 EP 1 IC.02.02.01 EP 1 LD.03.06.01 EP 3 MM.06.01.01 EP 3 PC.03.05.05 EP 4 PC.03.05.09 EP 1 PC.03.05.11 EP 1 HR.01.06.01 EP 1 HR.01.06.01 EP 6 IC.02.01.01 EP 1 NPSG.07.01.01 EP 1 NPSG.15.01.01 EP 1 NPSG.15.01.01 EP 5 NR.02.02.01 EP 1 PC.01.02.03 EP 4 PC.02.01.03 EP 1 PC.02.01.11 EP 2 RC.02.01.01 EP 2 EC.02.05.01 EP 15 EC.02.06.01 EP 1 IC.02.02.01 EP 2 HIGH HIGH Likelihood to Harm Likelihood to Harm EC.02.01.01 EP 5 EC.02.04.03 EP 4 EC.02.05.02 EP 4 EC.02.05.09 EP 8 EC.02.05.09 EP 11 EC.02.05.09 EP 12 EC.02.06.01 EP 20 LD.04.01.05 EP 5 LS.02.01.10 EP 14 LS.02.01.30 EP 3 LS.02.01.30 EP 12 LS.02.01.30 EP 19 LS.02.01.30 EP 20 LS.02.01.34 EP 3 LS.02.01.34 EP 9 LS.02.01.70 EP 5 LS.02.01.70 EP 6 LS.03.01.70 EP 6 MM.03.01.01 EP 2 MM.03.01.01 EP 3 MM.03.01.03 EP 1 NPSG.03.04.01 EP 1 NPSG.15.01.01 EP 7 UP.01.03.01 EP 2 RI.01.01.03 EP 1 TS.03.01.01 EP 9 EC.02.03.01 EP 1 EC.02.06.01 EP 26 HR.01.06.01 EP 5 MM.05.01.07 EP 2 PC.06.01.01 EP 4 PC.06.03.01 EP 3 EC.02.02.01 EP 5 EC.02.02.01 EP 6 EC.02.05.01 EP 23 EC.02.05.01 EP 24 EC.02.05.05 EP 6 IC.02.02.01 EP 4 LS.02.01.20 EP 14 LS.02.01.35 EP 6 MS.03.01.01 EP 7 MODERATE MODERATE EC.02.04.03 EP 3 IC.01.02.01 EP 3 IC.02.01.01 EP 2 IM.02.01.03 EP 2 LS.01.01.01 EP 3 LS.01.01.01 EP 6 LS.01.02.01 EP 3 LS.02.01.35 EP 4 LS.02.01.35 EP 5 LS.03.01.34 EP 3 PC.01.02.03 EP 5 PC.02.02.03 EP 11 RI.01.03.01 EP 1 WT.04.01.01 EP 2 MM.03.01.01 EP 7 LOW LOW LIMITED LIMITED PATTERN PATTERN Scope Scope WIDESPREAD WIDESPREAD
Risk Categories Risk Categories Leadership and Culture Leadership and Culture Behavioral Health Behavioral Health Sterilization and Reusable Instruments Sterilization and Reusable Instruments High High- -level Disinfection of Medical Devices level Disinfection of Medical Devices Scopes Probes Infection Control Fundamentals Infection Control Fundamentals Hand Hygiene Separation of Clean and Dirty Compliance with Surgical Attire Policy Supplies Supplies and and Equipment Equipment Medication Medication Management Management Environmental Safety Environmental Safety Medical Medical Record Record Documentation Documentation Human Human Resources Resources *Condition Level *Condition Level Findings Findings that put our ability to participate in the care of Medicare patients at risk Findings result in a requirement for: Immediate and long term Action Plans, a requirement to monitor performance data, AND Continuous process/performance data review by CMS/JC surveyors (including both virtual and additional on-site reviews) Findings (High Likelihood to Harm and Widespread Scope) (High Likelihood to Harm and Widespread Scope) AND
Survey Ready Patient Ready =
Call to Action Call to Action All Hands on Deck! All Hands on Deck! Successful Surveys require a team and a collaborative mindset You You are are here because you are an operational leader here because you are an operational leader You are the CEO of your area It is your responsibility to understand and mitigate risk in your area(s), ensuring adherence to all regulatory standards We have resources to support you We have resources to support you Subject Matter Experts (Tuesdays Before Two and Consultative) Performance Improvement Coaches to support your use of the Daily Management System Action Plan owners for identified risks Weekly Steering Committee meetings Strong connection to the CEO s Cabinet
Steering Committee Structure & Communications Steering Committee Structure & Communications A Steering Committee A Steering Committee is being formed to provide structure for Action Planning, Performance Monitoring (data), and to remove barriers for Project Teams Weekly Steering Committee Weekly Steering Committee P Progress rogress R Reports Weekly Medical Center Leadership Cabinet Reports Weekly Medical Center Leadership Cabinet Reports Escalation for resource needs or barriers encountered Communication plan for cascade and spread Established processes for monitoring adherence to standards Weekly Weekly emails emails for general survey readiness, to include informational materials and checklists To assess your areas of patient care oversight To cascade to your teams in your Daily Management System Huddles eports from each Project Team
The Daily Management System (DMS) The Daily Management System (DMS) We will use the UVA Be Safe Daily Management System to We will use the UVA Be Safe Daily Management System to identify and mitigate local patient/provider safety risk: identify and mitigate local patient/provider safety risk: Daily Huddles (identify risk and communicate mitigation strategies) Visual Management (of data demonstrating adherence and performance) Real Time Root Cause Problem Solving (with a Performance Improvement Coach) Escalation to: 10am Huddle JC Readiness Steering Committee CEO s Cabinet
The Daily Management System (DMS) (Cont.) The Daily Management System (DMS) (Cont.) All areas should refresh both DMS behaviors and Visual All areas should refresh both DMS behaviors and Visual Management Boards (VMBs) to reflect local risk and practice Management Boards (VMBs) to reflect local risk and practice expectations expectations All Chiefs will set expectations within their verticals, and will participate in Rounding/GEMBA to ensure that regulatory risk indicators are present on local VMBs Kathy Baker and Veronica Brill will begin Leader Rounds/GEMBA to check on leader execution of the DMS on on January 11 January 11th th All Inpatient Units will add Code Cart Checks, Refrigerator Checks and POCT Checks to their Visual Management Boards (VMBs) before January before January 9 9th th
ASPIRE ASPIRE Values Values This system will NOT work without constant reinforcement of our expectation of an environment of Professional Professional Safety Safety Leaders must routinely request team member s input, and must sincerely reward ALL call outs/escalation reward ALL call outs/escalation of potential risk Successful survey performance to the Leadership and Culture Standards Standards will require all leaders to demonstrate humble curiosity and servant leadership, as assessed by their team Leadership and Culture
Reminder Reminder ALL ALL practice must be guided by readily available policies, practice must be guided by readily available policies, protocols and guidelines protocols and guidelines approved by the appropriate approved by the appropriate committee and maintained in committee and maintained in PolicyTech NO NO local policies/documents will be honored by the JC and must be identified/retired before before March 1, 2024 March 1, 2024 Leader Rounding/GEMBA will include a status check regarding local policy/practice documents PolicyTech
Milestones Milestones
Whats Next? What s Next? Chiefs will be setting expectations setting expectations for their verticals in terms of (1) The cadence and content of Huddle, (2) the content of VMBs, (3) the cadence of GEMBA Goal: Our team members can speak eloquently to central and local safety risks and mitigation strategies (and data) Institution Institution- -Wide Refresh Wide Refresh of both DMS behaviors and VMBs to reflect local risk and practice expectations (and data) Leaders should promote promote an environment of Professional Safety, and emphasize ASPIRE values are upheld at all times Performance Improvement Coaches will be redeployed redeployed as resources Huddles, VMB maturity, and Problem-Solving/Escalation The ideal Huddle involves a collective understanding of central and local safety risks, and a discussion of current performance that includes up-to-date data Upcoming This Month: The Joint Commission Safety Survey Action Planning Team Leads Joint Commission Safety Survey Action Planning Team Leads will establish scope of work and meeting cadence Steering Committee presentations Steering Committee presentations Coaches will begin Daily Management System Maturity Assessments Daily Management System Maturity Assessments as a guide for GEMBA emphasize the expectation that as resources to all areas, and will support
Be Safe DMS/TJC Toolkit Be Safe DMS/TJC Toolkit TJC Action Plan Log Be Safe Refresh Materials Be Safe Leader Standard Work Daily Management System Maturity Assessment GEMBA cards Culture Survey
