Sharing Best Practices and Forging New Relationships: BWFH Team Participates in Mock Joint Commission Survey at Martha's Vineyard Hospital

The Joint Commission is an independent, not-for-profit organization that accredits and certifies healthcare organizations and programs in the United States. In order to prepare for the unannounced Joint Commission survey, many organizations choose to hold a mock survey where leadership and staff can practice interacting with surveyors. Recently, a team from Brigham and Women’s Faulkner Hospital traveled to Martha’s Vineyard Hospital to conduct a mock survey.

“After our most recent Joint Commission survey last fall, I presented our results to a group of Mass General Brigham clinical compliance leaders,” says Executive Director of Patient Safety, Quality, Risk, Infection Control, Clinical Compliance and CDI Christi Barney, MSN, RN. “My counterpart at Martha’s Vineyard Hospital, Escel Stanghellini, was impressed with how few findings we had, particularly around infection control, and asked me if I would be willing to put together a team for a mock survey. Escel and I first met working together on Nursing Quality issues when she was at Brigham and Women’s Hospital.”

Barney was more than happy to oblige. “A mock survey is a great opportunity to learn how other people do things, but also to share your own expertise and help your colleagues get ready for their survey,” she says.

The team at Martha’s Vineyard Hospital recently experienced changes to their Central Processing Department, so they were keen to focus on that area. As a result, Barney invited BWFH’s Central Processing Department Manager Sara Lourie along with Senior Project Manager for Infection Control and Clinical Compliance Tricia Martin, MPH, to join her.

The team arrived the night before in order to “sneak up” first thing the next morning just like the real Joint Commission surveyors would do. They spent the day visiting the various hospital departments, observing the environment of care and their safety processes.

“It was interesting to look at things from a different perspective and to see how a similar department is run,” says Lourie. “That was a learning opportunity for me.”

Lourie says she was able to make a few recommendations, particularly around outdated chemicals that had accumulated during the supply chain disruptions related to the COVID-19 pandemic. Seeing stockpiles of supplies at Martha’s Vineyard Hospital actually opened her eyes to similar stockpiles at BWFH, which she addressed upon her return.

Lourie’s interaction with the team at Martha’s Vineyard Hospital also opened up a new relationship. “We have regular meetings with Central Processing Department leaders across Mass General Brigham. My counterpart at Martha’s Vineyard Hospital has not participated in those calls previously. After spending time with me during the mock survey, they were inspired to begin participating,” explains Lourie. “They have since reached out a few times for support and resources.”

Martin had a similar experience. “It’s always beneficial to have a new relationship with another hospital within Mass General Brigham,” she says. “Both BWFH and Martha’s Vineyard Hospital have new Infection Preventionists on their teams. I was able to connect our new Infection Preventionist, Brittany Herrick, with theirs and they have since connected to share their experiences. It’s a great partnership.”

Overall, the trip was a great success and an eye-opening experience. “It gives me a great deal of empathy for our surveyors,” says Barney. “It’s a long day and you are thinking the whole time. You have to actively listen and be thoughtful about the way you interact with the staff. You don’t want to make them anxious or discourage them, but you are testing them. We tried to be the politest version of a surveyor I could be while also giving them a real experience so that they get the practice they need responding to surveyor questions.”

While it was rewarding to meet colleagues from within the system and learn from each other, one of the biggest take-aways the team had from their experience was the importance of teambuilding. Barney, Lourie and Martin all enjoyed spending a little time together outside of their regular roles. “It made me realize, given the intensity of the work we do, that it’s important to spend time with your team doing fun things,” says Barney. “Martha’s Vineyard Hospital were gracious hosts and I really hope that we did something useful for them. For us, it was like a mini vacation. We had a few hours the night we arrived to drive around and have dinner together and just get to know each other outside of the context of work. That was really nice.”