- Email: [email protected]
Creating The Joint Commission “Super User”
Solutions
Creating The Joint Commission “Super User” An Innovative Plan to Ensure Survey Readiness JEAN SALERA-VIEIRA, MS, RNC-OB, C-EFM SUSAN MAXWELL, RN, MBA, NEA-BC
p
Preparing for The Joint Commission accreditation survey can be a daunting process and it’s imperative to ensure that staff who work at the bedside are prepared when The Joint Commission arrives. In December 2010, we began planning a strategy to ensure preparation for the
summer 2011 visit from The Joint Commission. We needed to create a plan that would disseminate updated information to all hospital staff. In the past, various educational plans have been implemented to prepare the hospital for The Joint Commission survey. Indeed, other hospitals have also struggled with how best to prepare and have implemented educational plans and processes (Gantz, Sorenson, & Howard, 2003; Thompson et al., 2008; Thurber & Read, 2008).
The “Super User” Concept We decided to focus on a concept that has been utilized at our facility before—the concept of
Abstract Preparing for The Joint Commission accreditation survey can be a daunting process. To ensure staff readiness, we created a plan to disseminate updated information to all hospital staff. Harnessing the momentum of increased staff involvement through shared governance and the past successes of the “super user” role, The Joint Commission Super User (TJCSU) role was created. This article discusses the role of the TJCSU and its positive impact on our hospital’s readiness for and results of The Joint Commission accreditation survey. DOI: 10.1111/j.1751-486X.2012.01722.x Keywords Joint Commission accreditation | survey preparedness | shared governance
http://nwh.awhonn.org
© 2012, AWHONN
159
Solutions
the “super user.” As referenced in the clinical informatics literature (Boffa & Pawola, 2006; Halbesleben, Wakefield, Ward, Brokel, & Crandall, 2009; McIntire & Clark, 2009), the super user role aids in the success of the implementation of clinical informatics systems, including changes in the electronic medical record documentation. At our facility (Women & Infants Hospital in Providence, RI), the “super user” term has been used for staff members who have been champions and have worked on new initiatives within the hospital. Super users were critical to the success of the implementation of Computerized Provider Order Entry (CPOE). Typically, these super users are based on their own units to assist their colleagues with the current project/initiative. They receive additional training in the initiatives for which they are functioning as super users.
Joint Commission Super User Role Women & Infants Hospital was working to incorporate a shared governance philosophy into
the organization. This increased staff involvement and engagement at the unit level, as well as in hospital-wide committees. Harnessing the momentum of increased staff involvement and the past success of the “super user” role, we created the role of The Joint Commission Super User (TJCSU). As with any new process, there were skeptics among hospital employees at various levels. Concerns included whether or not the expense of this program was justified, whether this would be embraced by staff and/or result in a successful visit from The Joint Commission. Through careful planning and consistent support of the program, we set out to prove the effectiveness of the TJCSU role. The TJCSU group included 14 staff nurses from various inpatient units within the hospital. Through an agreement between the hospital administration and the union, each unit received 8 hours of “education” time dedicated to the TJCSU. The hours were either split between two RNs at 4 hours per RN or one RN at 8 hours. The TJCSUs’ hours came out of their regular schedules for those set hours each week,
Through careful planning and consistent support of the program, we set out to prove the effectiveness of the TJCSU role
Jean Salera-Vieira, MS, RNC-OB, C-EFM, is the clinical specialist for maternal child health at Kent Hospital in Warwick, RI. Susan Maxwell, RN, MBA, NEA-BC, is director for women’s services at Yale New Haven Hospital in New Haven, CT. Both authors were previously at Women & Infants Hospital of Rhode Island in Providence, RI, where the program described in this article took place. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
160
Nursing for Women’s Health
Volume 16
Issue 2
but this did not leave the units short of staff. This was not a budget neutral program; however, costs were minimized because the slowest day of the week was set as the scheduled TJCSU day. When weighing the pros and cons of taking on the additional costs versus not having a successful survey, the hospital was determined to use every resource available.
Orientation and Training TJCSUs each received a 3-hour orientation, which included the following information: • The definition of a sentinel event and the hospital’s response to such an event; • How to access The Joint Commission website; • 2011 National Patient Safety Goals; • Environment of care (EOC) standards; • How to access resources online and through SharePoint sites (hospital’s intranet); • How to conduct a tracer. The orientation served to increase staff awareness of regulatory compliance, which was traditionally in the hands of management. The tracer methodology, employed by The Joint Commission surveyors, is one in which the surveyors follow, or trace, a patient through the care experience. Part of the role of TJCSUs was to conduct tracers on their units every week. The super users randomly selected a chart to trace through the questions on the tracer tool. Although the role of super user is a familiar one, not all members of the TJCSU group had been in that role before. Part of the orientation time was spent discussing how best to approach peers on the unit with tracer questions and/or The Joint Commission information that needed to be disseminated on the unit. Following orientation, the quality liaison for The Joint
April | May 2012
Commission preparedness was available as a resource to the super users as needed.
Weekly Workgroup After orientation, the TJCSUs were incorporated into a weekly Joint Commission preparation workgroup, which met for 1 hour each week and included nurse educators, nurse managers, assistant nurse managers and additional staff from the inpatient and outpatient settings. Representatives from many disciplines within the hospital, including pharmacy, infection control, safety and patient and family experience, were also included. TJCSUs were charged with bringing information from the workgroup back to their units. There were often “homework” assignments given at the weekly meetings, such as
every unit had access to the same type of screening and/or education documentation. Using the input from the TJCSUs and workgroup members, the infection control department requested screens in the electronic medical record that would be consistent throughout the hospital. Once the screens were developed, the TJCSUs and workgroup members went to their units to educate their peers. One question on the inpatient tracer tool reads “Staff verbalizes knowledge to provide patient/family education on multidrug-resistant organisms.” In February 2011, most tracers were returned with “no” circled for this question. As the program progressed, we saw “yes” circled more often. Further, one of the super users reported that she is not asking the same staff, but is asking this question of dif-
We’ve observed a marked decrease in expired supplies found on the units, representing another improvement toward patient safety
completing a tracer each week, inspecting for any EOC infractions, teaching peers where to find trends in the record and dispersing new information from the workgroup to the units.
Effectiveness of the Super User Role The super users returned tracers back to the quality management department each week. Using these tools, we were able to track any areas that require increased education on a unit around Joint Commission requirements. We also tracked improvements on the units based on the super users’ education and work on their units. Specific topics were identified for improvement. For example, a considerable amount of time and education was spent on how to document multidrug-resistant organism screening and education for patients. What came to light during that time was that not
ferent staff and “they all seem to know the answer.” This is a direct result of the great work of the TJCSUs and the workgroup. The EOC concerns were also dramatically improved due to the impact of the super users. They became acutely aware of where supplies and equipment must be stored. We’ve observed a marked decrease in expired supplies found on the units, representing another improvement toward patient safety. We also saw, through the tracer tools, an improvement in the following question on the inpatient tracer tool: “Unobstructed access to gas shut off.” This indicates that equipment and supplies that may have been previously blocking the gas shutoff are no longer present in that area. Another area where the super users have influenced change is regarding single-use patient care supplies. Betadine has been supplied in single-use
Nursing for Women’s Health
161
Solutions
4-oz bottles throughout the hospital. The super users and workgroup members requested smaller bottles. Pharmacy was able to locate and order 2-oz bottles, which decreased cost and increased safety. These examples illustrate just some of the impact that TJCSUs and workgroup have had with all employees at our hospital.
Council within Shared Governance. One of the major responsibilities of this new council will be to ensure a constant state of readiness for regulatory compliance. We look forward to future visits with much anticipation and pride in an amazing team. NWH
Acknowledgments Outcome of the Joint Commission Survey When the Joint Commission arrived on June 20, 2011, we were well-prepared. Overheard in the corridors were staff who said, “Bring it on, we’re ready.” During the visits to all of the patient care areas, staff members were very proud and did an outstanding job of discussing the care they provide to patients. In fact, some were disappointed that the surveyors didn’t spend more time on their units. There was a spirit of camaraderie that is difficult to put into words. Our manage-
The authors would like to acknowledge the TJCSUs for all of their work to prepare for The Joint Commission survey at Women & Infants Hospital: Tracey Burns, Stephanie Carpenter, Ann Collins, Lisa Emery, Nancy Eno, Barbara Gendron, Joanna Jarvis, Melissa Maher, Ashley Makin, Gail Murray, Laura Payne, Laurie Persechino, Kara Randall and Donna Sullivan. The authors also thank Carol Opiekun, associate vice president of patient care services, and Denise Henry, director of quality management, for their support of the TJCSU program.
References During the visits to all of the patient care areas, staff members were very proud and did an outstanding job of discussing the care they provide to patients
ment team did a quick debriefing at the end of each day while The Joint Commission was present. The super users were invited to these meetings and most attended. At the end of the 4-day survey, we received no life safety citations, two direct and four indirect citations. We were elated with our findings and credit most of our success to our TJCSUs. We felt that the $40,000 total approximate cost of this program was well worth the results that we received. We had a huge barbeque cookout and celebrated a job well done together.
Conclusion The TJCSUs have gladly transitioned into our newly created Clinical Quality and Safety
162
Nursing for Women’s Health
Boffa, D., & Pawola, L. (2006). Identification and conceptualization of nurse super users. Journal of Healthcare Information Management, 20(4), 60–68. Gantz, N., Sorenson, L., & Howard, R. (2003). A collaborative perspective on nursing leadership in quality improvement. Nursing Administration Quarterly, 27(4), 324–329. Halbesleben, J., Wakefield, D., Ward, M., Brokel, J., & Crandall, D. (2009). The relationship between superusers’ attitudes and employee experiences with clinical information systems. Medical Care Research and Review, 66(1), 82–96. McIntire, S., & Clark, T. (2009). Essential steps in super user education for ambulatory clinic nurses. Urologic Nursing, 29(5), 337–342. Thompson, E., Pool, S., Brown, D., Clark, J., Ford, D., Gillett, C., … Zastrow, S. (2008). JCAHO preparation: An educational plan. The Journal of Continuing Education in Nursing, 39(5), 225–227. Thurber, R., & Read, L. (2008). A comprehensive education plan: The key to a successful jointcommission on accreditation of healthcare organizations survey. Journal for Nurses in Staff Development, 24(3), 129–132.
Volume 16
Issue 2
Creating The Joint Commission “Super User” An Innovative Plan to Ensure Survey Readiness JEAN SALERA-VIEIRA, MS, RNC-OB, C-EFM SUSAN MAXWELL, RN, MBA, NEA-BC
p
Preparing for The Joint Commission accreditation survey can be a daunting process and it’s imperative to ensure that staff who work at the bedside are prepared when The Joint Commission arrives. In December 2010, we began planning a strategy to ensure preparation for the
summer 2011 visit from The Joint Commission. We needed to create a plan that would disseminate updated information to all hospital staff. In the past, various educational plans have been implemented to prepare the hospital for The Joint Commission survey. Indeed, other hospitals have also struggled with how best to prepare and have implemented educational plans and processes (Gantz, Sorenson, & Howard, 2003; Thompson et al., 2008; Thurber & Read, 2008).
The “Super User” Concept We decided to focus on a concept that has been utilized at our facility before—the concept of
Abstract Preparing for The Joint Commission accreditation survey can be a daunting process. To ensure staff readiness, we created a plan to disseminate updated information to all hospital staff. Harnessing the momentum of increased staff involvement through shared governance and the past successes of the “super user” role, The Joint Commission Super User (TJCSU) role was created. This article discusses the role of the TJCSU and its positive impact on our hospital’s readiness for and results of The Joint Commission accreditation survey. DOI: 10.1111/j.1751-486X.2012.01722.x Keywords Joint Commission accreditation | survey preparedness | shared governance
http://nwh.awhonn.org
© 2012, AWHONN
159
Solutions
the “super user.” As referenced in the clinical informatics literature (Boffa & Pawola, 2006; Halbesleben, Wakefield, Ward, Brokel, & Crandall, 2009; McIntire & Clark, 2009), the super user role aids in the success of the implementation of clinical informatics systems, including changes in the electronic medical record documentation. At our facility (Women & Infants Hospital in Providence, RI), the “super user” term has been used for staff members who have been champions and have worked on new initiatives within the hospital. Super users were critical to the success of the implementation of Computerized Provider Order Entry (CPOE). Typically, these super users are based on their own units to assist their colleagues with the current project/initiative. They receive additional training in the initiatives for which they are functioning as super users.
Joint Commission Super User Role Women & Infants Hospital was working to incorporate a shared governance philosophy into
the organization. This increased staff involvement and engagement at the unit level, as well as in hospital-wide committees. Harnessing the momentum of increased staff involvement and the past success of the “super user” role, we created the role of The Joint Commission Super User (TJCSU). As with any new process, there were skeptics among hospital employees at various levels. Concerns included whether or not the expense of this program was justified, whether this would be embraced by staff and/or result in a successful visit from The Joint Commission. Through careful planning and consistent support of the program, we set out to prove the effectiveness of the TJCSU role. The TJCSU group included 14 staff nurses from various inpatient units within the hospital. Through an agreement between the hospital administration and the union, each unit received 8 hours of “education” time dedicated to the TJCSU. The hours were either split between two RNs at 4 hours per RN or one RN at 8 hours. The TJCSUs’ hours came out of their regular schedules for those set hours each week,
Through careful planning and consistent support of the program, we set out to prove the effectiveness of the TJCSU role
Jean Salera-Vieira, MS, RNC-OB, C-EFM, is the clinical specialist for maternal child health at Kent Hospital in Warwick, RI. Susan Maxwell, RN, MBA, NEA-BC, is director for women’s services at Yale New Haven Hospital in New Haven, CT. Both authors were previously at Women & Infants Hospital of Rhode Island in Providence, RI, where the program described in this article took place. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].
160
Nursing for Women’s Health
Volume 16
Issue 2
but this did not leave the units short of staff. This was not a budget neutral program; however, costs were minimized because the slowest day of the week was set as the scheduled TJCSU day. When weighing the pros and cons of taking on the additional costs versus not having a successful survey, the hospital was determined to use every resource available.
Orientation and Training TJCSUs each received a 3-hour orientation, which included the following information: • The definition of a sentinel event and the hospital’s response to such an event; • How to access The Joint Commission website; • 2011 National Patient Safety Goals; • Environment of care (EOC) standards; • How to access resources online and through SharePoint sites (hospital’s intranet); • How to conduct a tracer. The orientation served to increase staff awareness of regulatory compliance, which was traditionally in the hands of management. The tracer methodology, employed by The Joint Commission surveyors, is one in which the surveyors follow, or trace, a patient through the care experience. Part of the role of TJCSUs was to conduct tracers on their units every week. The super users randomly selected a chart to trace through the questions on the tracer tool. Although the role of super user is a familiar one, not all members of the TJCSU group had been in that role before. Part of the orientation time was spent discussing how best to approach peers on the unit with tracer questions and/or The Joint Commission information that needed to be disseminated on the unit. Following orientation, the quality liaison for The Joint
April | May 2012
Commission preparedness was available as a resource to the super users as needed.
Weekly Workgroup After orientation, the TJCSUs were incorporated into a weekly Joint Commission preparation workgroup, which met for 1 hour each week and included nurse educators, nurse managers, assistant nurse managers and additional staff from the inpatient and outpatient settings. Representatives from many disciplines within the hospital, including pharmacy, infection control, safety and patient and family experience, were also included. TJCSUs were charged with bringing information from the workgroup back to their units. There were often “homework” assignments given at the weekly meetings, such as
every unit had access to the same type of screening and/or education documentation. Using the input from the TJCSUs and workgroup members, the infection control department requested screens in the electronic medical record that would be consistent throughout the hospital. Once the screens were developed, the TJCSUs and workgroup members went to their units to educate their peers. One question on the inpatient tracer tool reads “Staff verbalizes knowledge to provide patient/family education on multidrug-resistant organisms.” In February 2011, most tracers were returned with “no” circled for this question. As the program progressed, we saw “yes” circled more often. Further, one of the super users reported that she is not asking the same staff, but is asking this question of dif-
We’ve observed a marked decrease in expired supplies found on the units, representing another improvement toward patient safety
completing a tracer each week, inspecting for any EOC infractions, teaching peers where to find trends in the record and dispersing new information from the workgroup to the units.
Effectiveness of the Super User Role The super users returned tracers back to the quality management department each week. Using these tools, we were able to track any areas that require increased education on a unit around Joint Commission requirements. We also tracked improvements on the units based on the super users’ education and work on their units. Specific topics were identified for improvement. For example, a considerable amount of time and education was spent on how to document multidrug-resistant organism screening and education for patients. What came to light during that time was that not
ferent staff and “they all seem to know the answer.” This is a direct result of the great work of the TJCSUs and the workgroup. The EOC concerns were also dramatically improved due to the impact of the super users. They became acutely aware of where supplies and equipment must be stored. We’ve observed a marked decrease in expired supplies found on the units, representing another improvement toward patient safety. We also saw, through the tracer tools, an improvement in the following question on the inpatient tracer tool: “Unobstructed access to gas shut off.” This indicates that equipment and supplies that may have been previously blocking the gas shutoff are no longer present in that area. Another area where the super users have influenced change is regarding single-use patient care supplies. Betadine has been supplied in single-use
Nursing for Women’s Health
161
Solutions
4-oz bottles throughout the hospital. The super users and workgroup members requested smaller bottles. Pharmacy was able to locate and order 2-oz bottles, which decreased cost and increased safety. These examples illustrate just some of the impact that TJCSUs and workgroup have had with all employees at our hospital.
Council within Shared Governance. One of the major responsibilities of this new council will be to ensure a constant state of readiness for regulatory compliance. We look forward to future visits with much anticipation and pride in an amazing team. NWH
Acknowledgments Outcome of the Joint Commission Survey When the Joint Commission arrived on June 20, 2011, we were well-prepared. Overheard in the corridors were staff who said, “Bring it on, we’re ready.” During the visits to all of the patient care areas, staff members were very proud and did an outstanding job of discussing the care they provide to patients. In fact, some were disappointed that the surveyors didn’t spend more time on their units. There was a spirit of camaraderie that is difficult to put into words. Our manage-
The authors would like to acknowledge the TJCSUs for all of their work to prepare for The Joint Commission survey at Women & Infants Hospital: Tracey Burns, Stephanie Carpenter, Ann Collins, Lisa Emery, Nancy Eno, Barbara Gendron, Joanna Jarvis, Melissa Maher, Ashley Makin, Gail Murray, Laura Payne, Laurie Persechino, Kara Randall and Donna Sullivan. The authors also thank Carol Opiekun, associate vice president of patient care services, and Denise Henry, director of quality management, for their support of the TJCSU program.
References During the visits to all of the patient care areas, staff members were very proud and did an outstanding job of discussing the care they provide to patients
ment team did a quick debriefing at the end of each day while The Joint Commission was present. The super users were invited to these meetings and most attended. At the end of the 4-day survey, we received no life safety citations, two direct and four indirect citations. We were elated with our findings and credit most of our success to our TJCSUs. We felt that the $40,000 total approximate cost of this program was well worth the results that we received. We had a huge barbeque cookout and celebrated a job well done together.
Conclusion The TJCSUs have gladly transitioned into our newly created Clinical Quality and Safety
162
Nursing for Women’s Health
Boffa, D., & Pawola, L. (2006). Identification and conceptualization of nurse super users. Journal of Healthcare Information Management, 20(4), 60–68. Gantz, N., Sorenson, L., & Howard, R. (2003). A collaborative perspective on nursing leadership in quality improvement. Nursing Administration Quarterly, 27(4), 324–329. Halbesleben, J., Wakefield, D., Ward, M., Brokel, J., & Crandall, D. (2009). The relationship between superusers’ attitudes and employee experiences with clinical information systems. Medical Care Research and Review, 66(1), 82–96. McIntire, S., & Clark, T. (2009). Essential steps in super user education for ambulatory clinic nurses. Urologic Nursing, 29(5), 337–342. Thompson, E., Pool, S., Brown, D., Clark, J., Ford, D., Gillett, C., … Zastrow, S. (2008). JCAHO preparation: An educational plan. The Journal of Continuing Education in Nursing, 39(5), 225–227. Thurber, R., & Read, L. (2008). A comprehensive education plan: The key to a successful jointcommission on accreditation of healthcare organizations survey. Journal for Nurses in Staff Development, 24(3), 129–132.
Volume 16
Issue 2