Hospital Accreditation

  1. Well it is that time again. Time for accreditation. Does your hospital gear up for this big time like mine does? I have worked there long enough to have gone through 5 or more of these. I wish they would just do unscheduled visits so the hospital always has to be in tip top shape.

    And every time there are more new things the accreditating body wants to see done. Things that the previous time weren't even on their lists. This time because our badges sometimes turn around and our faces/names can't be seen we are now going to have to get a second badge and put it on the back so if it turns around our name and face can be seen from both directions. Not that this is bad but the badges were fine 3 years ago.

    The management also makes sure staffing is real plush with strong staff on the days they make their visits.

    What has been your experience?
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  2. 7 Comments

  3. by   Katnip
    We just had our unannounced visit. We knew that at some point after Jan. 1 they would be coming, but not when. Talk about putting everyone under stress. The rumors that flew before they came...

    Anyway, our unit somehow managed to squeak by with no violations, in fact the inspectors said it was the most pleasant unit they visited. We didn't go overboard with staffing, just tried to maintain the usual...were lucky nobody called out that week.

    Still, it was hard when you have patients going bad and things going wrong and JCHAO is lurking around.

    Our badges flip around a lot, too. I just make sure to check now and then and set it straight. They didn't really seem to be bothered by that all that much. Their big things were improved comunication, pain management assessment and follow-up, and things like no IVs to gravity. Medication management was a biggie too. And knowing RACE and PASS.
  4. by   RNKPCE
    Thanks for your comments cyberkat.

    I hear now they are going to follow a patient from the entrance to our hospital whether it be ER, or pre- admit unit, til discharge. They want to see how the staff communicate the patients needs when they hand off a patient to another department. For instance, admit to er with abdominal pain, then to ultrasound, maybe OR, recovery room, surgical floor and discharge. They also want to know how competent staff are in caring for patient when they float to another unit.

    It is just the hubbub surrounding the visit that bugs me.
  5. by   Katnip
    Yes, that's what they did. They just sort of picked a patient, I'm guessing at random, and followed that patient through the system. They can start anywhere they want though, but they did seem to tend to start at ED or OR. But one day a group just started in ICU.

    They do check competencies. They will pick the patient and then ask the NM to see the files on the nurses and others taking care of that patient to make sure competencies are up to date. Not just floaters, everybody.

    I know. We had a resident who said, *either keep it this way all the time, or just be normal when they come. Quit stressing everybody out.*
  6. by   pwp1289
    we had our last 'scheduled' jacho visit a few months ago--now when they return in 3 years they can arrive any time unannounced !!!! and we go crazy getting ready for them--its amazing how all of a sudden things get repaired-polished-scrubbed-buffed and corrected when jacho is coming--overtime is nothing!!!!!! i am anxious to see what happens when they return
  7. by   orrnlori
    Quote from pwp1289
    we had our last 'scheduled' jacho visit a few months ago--now when they return in 3 years they can arrive any time unannounced !!!! and we go crazy getting ready for them--its amazing how all of a sudden things get repaired-polished-scrubbed-buffed and corrected when jacho is coming--overtime is nothing!!!!!! i am anxious to see what happens when they return
    I thought everyone was gonna have a cow the last scheduled visit. I can't imagine what it will be like when they show up unannounced. They drilled us on multiple things right before the visit to make sure we knew all the right answers to everything. I never saw any of them. We passed with flying colors, of course, we're a magnet hospital (big deal), maybe that made a difference. I think JCHAO is a joke. They just justify their jobs by adding more nuisance requirements. They need to worry more about patient to nurse ratios and things that make a REAL difference. Not whether our badges twirl around from time to time.
  8. by   sjoe
    "I think JCHAO is a joke. They just justify their jobs by adding more nuisance requirements."

    Yep.
  9. by   sharann
    They made SURE I was OFF the days JCHAO visited our hospital....Strange

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