1. Murray, Kathleen RN, CNA, MSN, vice president of patient care services

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Q I'm struggling to keep staff members in a constant state of readiness for an unannounced Joint Commission survey. Are there any creative ideas on how to make them take it seriously?


Unfortunately, there's no single process for helping staff approach the Joint Commission survey earnestly. It's beneficial to handle this in several different ways, but first and foremost it starts with leadership. Staff members that are most engaged are those whose managers are engaged and understand the survey process. It's important that you enlist a few of the managers that you find are "engaged" and demonstrate expert knowledge with the Joint Commission survey process to mentor you.


The following is a list of continuous readiness activities that have been successful for staff and leaders.


[black diamond] Move the accreditation culture away from survey preparedness to one of ongoing service and patient care preparedness.


[black diamond] Incorporate the standards into your organization's operational and strategic plans.


[black diamond] Create an accreditation committee with designated chapter leaders and mentor them to become experts in chapter standards.


[black diamond] Educate the accreditation committee, staff, and leaders in your organization about the standards, revision in standards, and expectations for compliance.


[black diamond] Assist staff and leaders with the development and implementation of corrective action planning.


[black diamond] Monitor and measure your success with ongoing self-assessment activities, such as a periodic performance review.


[black diamond] Devise a database to track, trend, and report compliance to the staff and leaders of your organization.


[black diamond] Perform mock survey tracer activities on an ongoing basis. Include staff, physicians, and leaders to help familiarize them with the survey process.


[black diamond] Merge standards compliance assessment activities into existing rounds and surveillance activities.


[black diamond] Use orientation processes to educate staff on accreditation expectations.


[black diamond] Hold an annual staff fair with a separate booth for each accreditation chapter or National Patient Safety Goals.


[black diamond] Publish weekly or monthly accreditation tips via e-mail or newsletter.


[black diamond] Meet with managers on a regular basis so they understand their role and the role of their staff in the accreditation process.


[black diamond] Encourage managers to place at least one accreditation topic on their staff meeting agenda each month. Invite the accreditation consultant or survey coordinator to speak with staff at meetings.


[black diamond] Integrate accreditation compliance into the staff performance evaluation process.


[black diamond] Network with other healthcare organizations to share strategies for continuous readiness.



Keeping staff and leaders engaged in this process is a challenge, and unannounced accreditation surveys are unavoidable. However, if continuous preparedness activities are successfully implemented, you can take the surprise out of survey activities for leaders and help your staff members feel more comfortable talking about patient care.

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Q What do you feel the best reporting relationship is for clinical nurse specialists-to the manager on the unit or to a centralized department?


It's important to keep in mind that the overall purpose for any reporting structure is to lay the foundation for building high-performing teams that meet the needs of the patients and the organization.


In my experience, one of the most highly functional advanced practice teams that I've worked with occurred when the clinical nurse specialists reported to a centralized department. The deployment of these resources provided proficient and valuable use of the clinical nurse specialists' expertise and was highly effective because the team was self-directed, productive, and viewed as a valuable resource. Additionally, a centralized reporting structure allows collaboration and consulting among the clinical nurse specialists, thereby lending their specific areas of expertise to any nursing units as requested.