Paper
Tuesday, November 15, 2005
This presentation is part of : Ensuring Quality in Practice
Shared Vision: Nursing and Quality Strategies for JCAHO Survey Readiness
Dorothy C. Foglia, RN, MS, Nursing, Children's Medical Center Dallas, Dallas, TX, USA and Paul J. Rosenbluth, MBA, CPHQ, Quality, Children's Medical Center Dallas, Dallas, TX, USA.
Learning Objective #1: Apply tactics and strategies to motivate and engage staff and leadership in survey readiness
Learning Objective #2: Create a sustainability plan for continual survey readiness

In the midst of leadership changes, and the completion of a new 132 bed-tower, Children's Medical Center Dallas was faced with the task of maintaining momentum and engaging the entire organization to prepare for our JCAHO survey. Just one year prior to survey and at a critical juncture in our development, an excellent survey was imperative to maintaining our reputation as a pediatric leader in healthcare. To accomplish this, Nursing and Quality leadership partnered to get to goal.

Traditional methods of a unilaterally driven project will not meet the expectations of today's rigorous JCAHO ‘Shared Vision' framework. Operating in silos is no longer acceptable or profitable. Therefore, at Children's we established our own ‘shared vision' of merging Nursing with Quality. Beginning with an Executive Steering Committee, we quickly transitioned to a frontline approach, involving key stakeholders in assessment, process, and evaluation.

The objectives of this session are to provide a framework of how to motivate and engage an organization in survey readiness and how to sustain the results. A sample of the topics that will be discussed include: the purpose of a readiness strategy team; how strategies were disseminated to organization leadership, physicians, and staff; the overall structure for reporting and monitoring progress; what initiatives were successfully implemented; how staff was prepared for the tracer methodology; and, what fast-track education methods were employed for all staff. Challenges and issues not well-received or carried throughout the organization will be discussed in addition to the pros and cons of each tactic.

The new JCAHO methodology no longer permits organizations to “cram for the exam.” Therefore, a culture of safety and quality – which results in survey readiness – must be embedded within the organization. Through this journey, Nursing and Quality created a vision and established the highest standards to provide safe, quality care.