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SPOTLIGHT
Getting Prepped ST. ANTHONY’S IS PREPARING FOR JOINT COMMISSION SURVEY
2 BY THE NUMBERS
Joint Commission survey
3 IN YOUR WORDS
Molly Glaser, RN, CRN, conducts a daily inspection of a crash cart.
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How are you Joint Commission survey ready?
6 BETTER MEDICINE
An interview with Russell Schroeder
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Joint Commission Survey Benjamin Ojie, RN, scans a medication into a patient’s electronic medical record.
More than
21,000
Health care organizations and programs in the U.S. accredited by The Joint Commission
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18 250 27 More than
Number of Accreditation Requirements
3,000 Zero
Departments at St. Anthony’s that are not involved in survey readiness
SPOTLIGHT
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Times in the last decade St. Anthony’s has passed the Joint Commission survey inspection
Minimum number of months between Joint Commission accreditation surveys Number of St. Anthony’s staff who serve on the 2016 Regulatory Readiness Steering Committee
Individual elements of performance
18 Chapters of Joint Commission standards governing hospital care
Three
Number of years the hospital accreditation is valid “Foaming in” before entering a patient’s room is an important component of hand hygiene protocol.
How are you Joint Commission survey ready? Our winner:
Having been through this survey multiple times, I am well aware of what the surveyors deem important. I have been walking through the unit and seeing it through their eyes. Maintenance has been contacted to fix things that are currently in ill repair. I have encouraged my co-workers to abide by all infection control and patient care area guidelines. I have reviewed documentation to ensure it genuinely reflects the excellent care provided to my patients, and I have reviewed policies and procedures to be ready to answer any questions. But, truthfully, I do these things all the time. Shouldn’t we all? Shouldn’t we be survey-ready EVERY SINGLE DAY?
Paula Musgrove
PT Acute Rehab
Meliha Sinanovic and I are educating nurses, techs, physicians and staff regarding proper hand hygiene and personal protective equipment (PPE) compliance. This helps prevent the spread of infection and helps us prepare for the Joint Commission survey. Jen Jaffe, BSN, RN Infection Prevention and Control
My office partner and I assist in tracking information on the After-Visit Summary (AVS) and clarify any details of teaching that the patient needs after discharge. The After-Visit Summary is the view we see of the patient’s discharge instructions. Anita Rogers Patient Relations
I have been making sure to be more diligent about charting. For example, every time I return a phone call to a patient who has left a voicemail, I make sure to write a short note stating what they called about and what the resolution was. This makes it easier for the whole team to know what is going on with our patients. Brittani Coffey, RN, BSN Heart Specialty Associates-Electrophysiology Office
It becomes routine for us to walk through our department without really looking for potential safety hazards. As I walk through the department I will take a few seconds to look for potential safety hazards that could affect patients and staff. It could be as simple as are the halls clear? Are the cords on our equipment in good working condition? Yvette Fritts, RMA Heart Specialty Associates
Being nice, ensuring patient safety, being accommodating and working hard! Live by those four things and we are sure to pass with flying colors! Athina Ott, RMA St. Anthony’s Internal and Geriatric Medicine
Although I rarely have direct patient contact, I ensure all Health Insurance Portability and Accountability Act (HIPAA) laws are enforced, encrypt any emails sent with HIPAAprotected information, and distribute and secure any HIPAA-printed data that may be left at the shared printer. One small thing I love to do is, if I come across a patient or family member who looks lost, to help them get to where they need to be. They have enough on their minds already! Julie Thompson, MBA Decision Support It is important to greet and welcome patients, family, friends and visitors and offer my assistance. I make sure to remember our Guiding Behaviors, practice AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank You) and always obey the Health Insurance Portability and Accountability Act (HIPAA) laws, practice good hygiene and keep eye contact. The most important gesture is to smile to make everyone feel much less anxiety. Cynthia Steiger Information Desk DECEMBER 2016
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Kate Hodges, RN, performs surgical counts of supplies, such as intruments, sponges and needles.
Molly Glaser, RN, CRN, right, leads the staff of 5 West in a discussion of survey readiness booklets.
St. Anthony’s readies for Joint Commission survey through best practice
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Corey Oberlander, RN, BSN, CRN, updates a patient’s plan of care for the day on the dry erase board in the patient’s room.
I think our staff is pretty knowledgeable, and we learn something new every day. Molly Glaser, RN, CRN
SPOTLIGHT SPOTLIGHT
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n an average day, clinical resource nurse Molly Glaser, RN, CRN, oversees hundreds of details relating to patient care on the fifth floor. Among other tasks, she makes staff assignments, works with patients who have questions, and provides assistance and guidance to less experienced nurses. Molly’s workload also includes ensuring that 5 East and 5 West are always up to regulatory standards – to ensure the best care for our patients and to always be ready for a survey by The Joint Commission. The survey for the hospital’s triannual accreditation inspection could happen tomorrow, or anytime through March 2017. Keeping her team ready is also a key part of this readiness--continuing education is a key part of this: recently, Molly and her team hosted a demonstration on isolation precautions at their daily staff huddle. Molly also works with nurses to help them navigate the policies and procedures outlined on the SAMCare intranet site. Then there are the recurring checks of the crash carts and automatic external defibrillators to ensure they are ready for an emergency, and the daily log-in of temperatures in each of the clinical refrigerators. “I think our staff is pretty knowledgeable, and we learn something new every day,” said Molly, a nurse at the medical center for 10 years. “We want to do really well with this survey, so the public feels confident coming to our facility.” The survey covers 250 Accreditation Requirements. Each requirement has additional elements that outline the specific action(s), process(es), or structure(s) that must be implemented to achieve the goal of the requirement. There are approximately 3,000 of these elements of performance. That might seem overwhelming, but they all break down to best practice, said Brent Grazman, Vice President of Operational Excellence.
“It’s really about providing good healthcare,” Brent said. “We need to be ready every day, not just when we know the Joint Commission is coming.” The standards are grouped into 18 chapters. Some examples include: Patient Rights, Infection Control, Medication Management, Human Resources, National Patient Safety Goals, Performance Improvement, Medical Staffing and Environment of Care. No detail is too minor: for instance, shipping boxes used outdoors are not allowed in interior areas that house medical supplies. Even the layout of the medical center must be in order: fire doors must be in the locations indicated by the medical center’s building plans, and they must operate as intended. The rules are there for a good reason, Brent noted.
It’s really about providing good healthcare. — Brent Grazman, Vice President of Operational Excellence “Many of today’s Joint Commission standards stem from problem areas found by surveyors in the past that adversely affected patient care,” Brent said. “In some instances, adopting these standards represents a change in our procedures, and change can be difficult. But that’s what we want to do, so that we can up our game in patient safety.” Medical center staff have been working with a consultant, Premier Inc., to prepare for the survey. A mock survey in early May revealed the medical center’s strengths and opportunities for improvement, and St. Anthony’s Regulatory Steering Committee meets weekly to double down on the latest developments. A group of employees designated “survey ninjas” help with communications in departments throughout the medical center. “What we’re trying to achieve is constant readiness, so we’re not trying to catch up,” said Patti Storey, Director of Quality Management. “We feel that the surveyors could walk in here any day, and we’re confident that we will do well on the survey.” For Corey Oberlander, RN, BSN, CRN, serving as a Clinical Resource Nurse on 7 West includes the survey-ready duties of helping the floor nurses with crucial checks and protocols. They include monitoring and removing oxygen from patients who are going through a stroke workup; monitoring of both IV- and mouth-administered pain medication, and its effects, to ensure adequate pain management for patients; and providing stroke education daily to each stroke patient on the floor. Corey’s supervisor, Marie Graham, RN, BSN, Nurse Manager of Medical Oncology/Neuro Medicine, provides updates to the staff during huddles on Tuesday and Thursday mornings. “It’s a lot for the nurses to remember when they’re doing their charting, but we’ve made a lot of improvement recently,” said Corey, who also serves as chair of the Nurse Research Council. “We have a little binder that we use to write everything down, and it helps us to know what to look for on everyone’s chart.”
Patti Storey, Director of Quality Management, evaluates the current status of the survey and prepares a communication for senior leadership.
St. Anthony’s Regulatory Readiness Steering Committee Below are the chairs and co-chairs of St. Anthony’s Regulatory Readiness Steering Committee, which meets weekly to keep abreast of the latest developments in best practices: Robert Hicks Melissa Stein, DO Katie Horton Linda Merz Tom Johnson Bill Hoefer Scott Symank Kelley Pruden Carol Ellis Russell Schroeder Kathy Stemler Leslie Thomas Carrie Gregory Leisa Huie
Linda Behnen Amy Alexander Sandy Boyer Eric Sullivan Michelle Jost Patricia Storey Gretchen Ott Joseph Forand, MD Natalie Wright Cathy Abrams Marie Graham Mary Schuh Ruth Southards Diane Hawkins DECEMBER 2016
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AN INTERVIEW WITH
Russell Schroeder Chief Nursing Officer
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Russell, 48, previously An interview with served as Chief Nursing Officer at Saint
Russell Schroeder grew up in Jerseyville, Ill., and he now lives in the Godfrey-Alton area with his wife of 24 years, Renee, a nurse practitioner. They have a son, Tyler, 21, and a daughter, Megan, 18. Also sharing their home are three dogs: Bear, a Shih Tzu, Cam, a black Lab; and Bennett, a French bulldog.
SPOTLIGHT SPOTLIGHT
Louis University Hospital. He also has served as director of the Emergency Department at BJC Christian Hospitals Northeast and Northwest, and as a Nursing Director at St. Anthony’s Health Center in Alton, Ill. He has worked as an ICU and ED nurse and as an EMT and an ICU tech, and he’s worked in case management and in quality improvement. Russ holds a bachelor’s degree in Nursing from McKendree University and a master’s degree in Health Care Administration from Lindenwood University. Russ, why did you decide to become a nurse? When I was young I thought I wanted to be a police officer. I felt it would be a way of helping to make a difference for people. As preparation, I took an EMT ride-along class that I really enjoyed. After that, I started working for a local ambulance company. It introduced me to health care, being in and out of hospitals, and meeting nurses and physicians. Most importantly, it fulfilled my goal of making a difference in people’s lives.
What sets nursing apart from other occupations? I like the flexibility: the ability to work in a home care setting, an administrative position like I’m in now, case management, or at the bedside, all of which are excellent careers and options. You see people at their best, such as new moms or orthopedic patients who are excited about their prosthetics and new mobility; and you also see people at some of the roughest times of their lives, and you make their lives more enjoyable. Nurses are the eyes and ears and the extensions of the physicians, 24/7, in a hospital.
In nursing, “growing our footprint” means getting people through the system efficiently so they have a great experience and want to make this their hospital of choice. — RUSSELL SCHROEDER
Russ met Renee when both were graduate nurses at McKendree University in
What day-to-day functions does your position entail? I attend a lot of meetings, many of which focus on patient safety and patient satisfaction: how do we impact patients? How do we make it a better work environment for the employees? How do we recruit the right people? How do we look at programs and needs to help retain the right people? The hospital recently rolled out strategic goals for fiscal year 2017, and a lot of my job is focused on those: quality, safety, people, providing people with the right tools and growing our footprint in the community. In nursing, “growing our footprint” means getting people through the system efficiently so they have a great experience and want to make this their hospital of choice.
Lebanon, Ill. “She’s really helped me
throughout my career,” he said. When he unwinds at home he likes to work with his hands, tinkering around the house
and restoring motorcycles and cars with
Tyler. Exercise also is a priority: Russ has
participated in a couple of marathons and half-marathons.
What keeps you in this high-stress field? At the end of a bad day, when I have hundreds of emails and I feel like, ‘Why am I here?’ I get out on the units, talk to the nurses and see what they need. If I can make their jobs better, they’re going to make the patient experience better and safer for our patients. I like to round, because I get charged and energized and better at what I do, and it helps me remember why I’m here. My belief is if you do what’s right for the patients – provide a safe, warm, healing environment, and provide the appropriate staffing, you are going to see growth and be a successful organization.
DECEMBER 2016
Alexa Clark, Policy and Data Quality Coordinator, researches and prints policies that are requested by the surveyors.
Angie Siesener, RN, checks a patient’s vital signs. Patients getting a stroke workup must maintain an oxygen saturation above 94 percent.
SURVEY SMARTS:
The Joint Commission
H At right: Stroke education includes this carbon copy, which goes home with the patient for reference regarding their stroke, risk factors, and how to prevent future strokes. Stroke education must be carried out daily for inpatients receiving a stroke workup.
ospital accreditation is voluntary, but it’s an important indicator of a hospital’s commitment to meeting performance standards and helps ensure reimbursement from insurance companies and the Centers for Medicare and Medicaid Services. There are other accrediting bodies, but the not-for-profit Joint Commission is considered the gold standard, said Patti Storey, Director of Quality Management. Founded in 1951, The Joint Commission has been accrediting hospitals for more than 60 years. Approximately 77 percent of the nation’s hospitals are accredited by the Joint Commission. “The Joint Commission standards ensure quality patient care, ensure the functions of the hospital are moving safely for normal business, and ensure we are prepared for any type of disaster,” Patti said. The team of surveyors (the number varies) can include doctors, nurses and other health
professionals and visits from anywhere from three to five days. They inspect the areas they choose, and are accompanied usually by the director of the department they are visiting and scribes who communicate with the command center, said Liz Schelp, who has served in the past as Regulatory Readiness Coordinator. Quality Management serves as a command center during this time, communicating with department directors on the surveyors’ schedule, destinations and activities. St. Anthony’s passed its previous triannual survey with minor conditions that were corrected. In addition to the hospital, Home Care/Hospice and Hyland Behavioral Health each are subject to separate 18-chapter, 3,000-standard surveys of their own. “The survey team is that extra, third-party eye that will say, ‘What you guys are doing is absolutely what we feel is the safest-quality care,’” Liz said. “Or, ‘What you’re doing, we feel, does not meet the safest quality of care that we can give, and you need to fix it.’”
Spotlight is published quarterly by the Marketing Department of St. Anthony’s Medical Center. Writer: Robbi Courtaway, ext. 4003 Photographer: June Potts, ext. 4934 Graphic Designer: Stephen Walker, ext. 4767