JCAHO coming in September...need ideas to get staff ready

[tuttlebug]

For some unknown reson my nurse manager "volunteered" me to be a committee to help get our unit ready for JCAHO. Our first meeting is Monday. Can anyone share anything that worked for them. Major problems include poor documentation and staff that are scared to answer questions so the just say the first thing that pops into their head.

I personally feel that it is a hopeless situation since on anygiven day about 50% of our nurses are agency/travellers and with the other 50% we have a very high turnover rate. Anyhow, since Im on the commitee I want to do my best.

Any ideas? Anyone?

Holly

[June55Baby]

I am the JCAHO Coordinator at our hospital so I am in charge of getting ALL staff, physicians and volunteers ready for unannounced survey in 2006.

Some ideas of what I have been doing to prep staff include:

Weekly chart review looking for prohibited abbreviations, incomplete documentation, missed assessments, etc. Then discuss 1 on 1 with the "offending" (for lack of a better word) person as an education effort.

"Mock Tracer" where you take a patient's chart and "trace" his or her stay while on your unit. Again looking for anything that would be non compliant with your policies and/or JCAHO Standards and talking with staff about how they do their work all along the way.

Survey Readiness Question of the Week - question related to Infection Control, Patient Safety, Environment of Care, Medication Management etc that the surveyors could ask.

Scavenger hunts - looking for expired products, food, etc.; looking for specific policies, plans, MSDS, etc; looking for safety issues; looking for infection control issues e.g. dirty ceiling tiles, overflowing linen carts, uncovered linen, dirty refrigerators, etc.

JCAHO will be looking to see if your practice is consistent with your policies. If your policy says you use the patient's name and Medical Record # as identifiers, is that what your staff say AND do?

Just a few of MANY, MANY ways to get started. You are lucky that you know when JCAHO is coming, next year they will arrive unannounced!

Good Luck!

[UM Review RN, ASN, RN]

Our educator puts printed "reading material" up in the staff bathroom, where we're sure to have something to read. I've learned a lot from reading the walls during potty breaks. :chuckle

[eneed1566]

I do weekly JCAHO questions of the week, I post 2 questions and then draw the winner out of a list of correct answers. The winner chooses a prize. We are also holding a JCAHO Carnival where each department is setting up a booth with questions related to their department and the staff will go through each station and answer the questions.

Just because you have agency staffing your hospital doesn't mean they aren't responsible for their actions and you need to make them aware of this. If you are obtaining JCAHO certification then they must adhere to your policies. JCAHO will question agency nurses!

Another fun thing to do is to see who can find the most expired item. We had a battery that was found the expired over 10 years ago. This is best for the original survey since you are constantly outdated once you're a part of JCAHO.

The best way to get the staff involved is simply to try and make a game out of it.

[naggytabby, BSN, RN]

this takes time but it worked very very well:

make up a small booklet with the info that jcaho asks- inlcuding acronyms like RACE, PASS; where do our biohazards go; where is this and that manual?; hwat committees do we have- it's well worth it. every staff member gets a copy- and i mean EVERYONE. different depts or groups take a week where they go around and quiz people- made it a fun game, and involved EVERYONE. created unity, comradery and increaseed morale...