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In This Issue:
Elizabeth Glaser, vice president of Clinical Services, Lisa Whittemore, BWPO department administrator, and Gail Morrissey, Clinical Compliance manager, left no closet unopened or question unasked when they posed as JCAHO surveyors and swept through Southern Jamaica Plain Health Center (SJPHC) last week.
“Without any notice at all, the staff at SJPHC were able to pull together, answer our questions and show us how they comply with organizational policies,” said Morrissey, who, along with members of the Ever Ready Team and executive leadership, conducts practice surveys to help staff prepare for BWH’s upcoming, unannounced JCAHO survey. “When JCAHO surveyors show up at the hospital sometime in 2007, we will be notified the morning of their visit, and we need to be prepared, just as SJPHC was last week.”
SJPHC Executive Director Tom Kieffer, Regina Harvey, RN, nurse manager, and Marisol Figueroa, practice coordinator, led the “surveyors” on a tour of the facility while answering questions about systems and processes in place at the community health center.
Morrissey quizzed Kieffer, Harvey and Figueroa on everything from the National Patient Safety Goals to advanced directives and how managers communicate policy changes to employees. She inspected medication cabinets for expired medications, checked that supply closet doors were locked if necessary and that patient rights information was posted where appropriate.
At the end of the survey, Morrissey, Glaser and Whittemore congratulated SJPHC staff on a job well done, and admired the center’s patient suggestion board located in the waiting area of SJPHC. Patients write suggestions, which are posted on a bulletin board along with an answer from staff at SJPHC.
In addition to Kieffer, Harvey and Figueroa, several SJPHC staff proved they are survey-ready. Morrissey rewarded staff with fun prizes including candy, plastic jewelry and small toys.
Mazie Anckle, RN, came running when Morrissey tested the nurse call button in the patient restroom. Anckle also detailed the policy for receiving critical test results.
Flavia Teixeira, RN, let the survey team know how patients are informed of their rights at SJPHC.
Abigail Ortiz, health educator, answered questions about the National Patient Safety Goals and the fire escape routes and staff meeting place.
From left: Lisa Whittemore, Marisol Figueroa, Tom Kieffer, Elizabeth Glaser, Regina Harvey and Gail Morrissey; Abigail Ortiz answers Morrissey’s questions; Flavia Teixeira explains how patients are informed of their rights; Glaser and Morrissey join Mazie Anckle, who holds up the prize she won for being a survey star.
2007 National Patient Safety Goals
1 Improve the accuracy of patient identification.
2 Improve the effectiveness of communication among caregivers.
3 Improve the safety of using medications.
4 Reduce the risk of health care associated infections.
5 Accurately and completely reconcile medications across the continuum of care.
6 Reduce the risk of patient harm resulting from falls.
7 Encourage patients’ active involvement in their care.
8 The organization identifies safety risks inherent in its patient population.