Susan Shevlin, RN, president, AHHRA of Greater New York, greets members at the April 23 seminar in Manhattan on preparing for The Joint Commission survey.
MANHATTAN — The Association of Healthcare Human Resources Administrators of Greater New York conducted an April 23 seminar on preparing for The Joint Commission survey.
During the seminar at Gannett Co. Inc.s corporate headquarters, human resources professionals whose facilities recently had undergone a survey shared their experiences and best practices for achieving success.
Susan Shevlin, RN, MA, MEd, president of AHHRA of Greater New York and assistant vice president, talent acquisition, for the North Shore-LIJ Health System, welcomed the seminars speakers — Maureen E. Morris, vice president, HR, St. Charles Hospital, Port Jefferson, N.Y.; Sheila McGrath, senior director, HR, Montefiore Medical Center, Bronx, N.Y.; and Pamela Duffy, vice president, HR, South Oaks Hospital, Amityville, N.Y. — who offered tips on preparing for a visit from The Joint Commission.
St. Charles Hospital was awarded three-year accreditation from The Joint Commission and earned its Gold Seal of Approval after a four-day survey. Morris walked attendees through each day, noting ways the team handled each obstacle. An important revelation, she said, was to be prepared, whether your facility is anticipating a survey or not.
“Keep everything together and be prepared at all times, not just before the survey,” she said. Morris also recommended having a leadership meeting at the end of each day to go over issues and to prepare and troubleshoot for the next day.
South Oaks Duffy agreed with Morris about survey readiness. “Going out of your way to make sure youre not ‘gearing up for surveys is good advice,” she said. The Joint Commission also surveyed South Oaks Hospital, a facility that offers mental health services. Duffys best tip is to ensure that all key players are equipped to take the lead if a facilitys lead person unexpectedly becomes unavailable.
“Our director of performance improvement happened to be on vacation at the time [The Joint Commission] announced they would be coming,” Duffy said. “Our chief nurse executive ended up coordinating the first day.”
Duffy warned attendees to be aware that complaint and grievance procedures were new for the 2013 survey and had posed a challenge when surveyors asked her HR department for contracted workers service files.
“They asked ‘How do you know that a contracted worker is competent?” she said. “We dont ask for this information for contracted workers and they wanted performance evaluations, primary source verifications and competencies, but we had other systems in place that saved us.”
To prepare for Montefiores five-day survey, McGrath and staff arranged a mock survey conducted by an outside agency, a tip she recommends for any organization anticipating a visit. Staff is less likely to be comfortable with an outside agency, she said.
The Joint Commission sent 15 surveyors to review Montefiores four hospitals, home health and hospital addiction programs, and faculty practice. McGrath set up an HR command center and made sure a staff member stayed with the surveyors, ensuring they didnt go anywhere by themselves.
Another important tip McGrath offered is to document when staff are doing the right things.
Tracey Boyd is a regional reporter.