Mock survey helps prepare BWFH for a visit from The Joint Commission

At Brigham and Women’s Faulkner Hospital, we are now within our Joint Commission survey window, which takes place every three years. We anticipate Joint Commission surveyors will be on site any time between now and early 2023. To prepare for the unannounced visit, the hospital recently participated in a mock Joint Commission survey with help from Chartis. 

Over the course of three days, mock surveyors Kim Wilson, RN, Phillip Boaz, RN, Ann Smedley, RN, and Steve MacArthur were accompanied by members of the hospital’s Quality, Safety, Risk, Compliance and Infection Control team, as well as representatives from the Department of Nursing and Facilities, as they inspected every area of the hospital using The Joint Commission’s Tracer Methodology.

In her final report, Wilson wrote, “It was abundantly clear by all Chartis team members that staff were dedicated to ensuring that patients received the highest quality of care they possibly could in a safe environment.” Of the staff interviewed during the mock survey, she noted a sense of pride, commitment and dedication.

However, despite the praise, several areas with room for improvement were noted on the mock surveyors’ report—chief among them was the management of wounds and general infection control.

“We did not invite Chartis to BWFH for them to tell us what we’re doing right,” says Chief Medical Officer Scott Schissel, MD, PhD. “We asked them here to serve as a fresh set of eyes in order to help us identify areas of concern that Joint Commission surveyors would surely find. While it can be tough to hear that we have areas in which improvement is needed, I am confident this information will be invaluable as we prepare for our survey. Already, teams are reviewing their workflows and making adjustments to improve patient safety based on these findings.”

Among their concerns related to wound care, Chartis found evidence that, although wound care guidelines exist, many could not be implemented outside of a provider’s order. Chartis suggested development of protocols or order sets to support quicker execution of evidence-based treatment of wounds. When it comes to general infection control, the surveyors noted instances of environmental issues such as high dust and concerns with process when it comes to cleaning surgical instruments at point of use and turning over rooms in the OR, as well as things like temperature logs for patient nutrition refrigerators that were not properly completed and expired products, among other findings.

“This will be my first Joint Commission survey as Director of Infection Control, Clinical Compliance and Patient Safety and I am committed to making it a successful one,” says Andrea Shellman, MHSA, CPPS. “While our mock survey results pointed out areas of weakness, I am confident we can rectify them and be better positioned for The Joint Commission’s visit. I encourage all staff to keep up the good work and please don’t hesitate to reach out if you have a safety concern in your area.”

Throughout the summer and fall, department leads will work closely with the Quality, Safety, Risk, Compliance and Infection Control team to ensure all concerns noted on the mock survey are addressed and help staff feel prepared to speak when Joint Commission surveyors arrives.

Are you prepared to speak with a Joint Commission surveyor? For help preparing, visit the Continuous Readiness page on BWFHconnect.

Published 8/2/22