April 5, 2023

After a successful mock survey in January, teams across the organization are anxiously awaiting the official visit from the Joint Commission. While visits are unannounced, we’re anticipating their arrival in late April or May.

To help our teams get ready, new Education Carts were rolled out across the Medical Center, The Woodlands and West Campuses and have had nearly 1,500 interactions with team members. The carts have proven to be a fun way to test and refresh everyone’s skills and knowledge and engage with leaders.

“The carts have been a big hit,” said Lindsay Meade, assistant clinical director, Perioperative Services. It’s fun way to help everyone get prepared and in the right mindset for the survey. We want to put our best foot forward and getting team members to buy in will help ensure our success.”

Be on the lookout for the Education Cart rolling in to your unit. Other ways to get prepared include reading the Tip of the Week and reviewing the Joint Commission SharePoint site.

The feedback given during the mock survey reinforced what we’re doing well and identified the biggest areas of improvement. While there are specific directives for each unit, some general trends and key areas of opportunity emerged:

  • Equipment: ability to speak to what is clean and what is dirty in the environment
  • Crash Carts: ensure logs are complete
  • Tape: Tape Removal Day is April 6
  • Medication and Sharps: secure medications and sharps
  • Inpatient Dashboard: leaders to monitor documentation to help remind and educate

The Joint Commission’s mission is to make health care a high-reliability industry by ensuring a commitment to continuous improvement in patient care. Our accreditation from the Joint Commission provides “deemed status” for CMS reimbursement, as well as shows our commitment to excel in providing safe, effective, high-quality care.

May 9, 2017

Texas Children’s recently received an impressive report card from The Joint Commission with surveyors commending the hospital for demonstrating several best practices.

“Our survey results are a great indication that we are meeting the expectation of quality care for our patients,” said Texas Children’s President and CEO Mark A. Wallace. “This should only propel us to continue our focus on providing safe, quality care every single day for every one of our patients.”

Every three years, Texas Children’s undergoes an accreditation process to ensure our delivery of high-quality patient care. On May 1, the Joint Commission survey team arrived at Texas Children’s for a 5-day unannounced survey. The surveyors consisted of an administrator, a pediatrician and ambulatory specialist, four pediatric and OB/GYN nurses, and a life safety engineer.

What Joint Commission noted

The survey is intended to assess the organization’s compliance in patient care areas that contribute to positive outcomes and to measure and improve performance. The Joint Commission team was very impressed with our improved outcomes in asthma, diabetes, radiology efficiency and flow, patient flow and surgical complications.

The team also identified several best practices observed during the survey including:

  • Time out processes across the system
  • NICU infection control practices
  • Error prevention technology in the anesthesia and pharmacy areas
  • Critical lab documentation
  • Simulation of new buildings and processes for latent safety threats

“The Joint Commission survey team visited several Texas Children’s facilities to evaluate patient care processes through on-site observations, staff interviews and tracer methodology,” said Texas Children’s Quality and Safety Director Elaine Whaley. “This year, Joint Commission implemented a new survey methodology called Survey Analysis for Evaluating Risk (SAFER), a matrix that uses a color-coded grid to evaluate the likelihood of harm to our patients, staff and visitors based on the number of occurrences.”

The surveyors were impressed with the knowledge and confidence exhibited by staff and faculty who participated in the tracer interviews. They complimented them on their ability to navigate Epic and explain the continuum of care, and they were impressed by our staff’s ability to talk about quality projects and outcomes.

How we prepared for the survey

Preparing for regulatory surveys is an ongoing process underscored by Texas Children’s daily focus on patient safety and high quality programs. Texas Children’s uses a consultant on an ongoing basis to review our processes and evaluate our survey readiness. The information provided by the consultant helps the organization fine tune.

“The results we get from area tracers during the preparation process provide information we need to develop and implement an organization-wide readiness education program,” said Danyalle Evans, Texas Children’s assistant director, System Accreditation and Readiness. “We regularly evaluate our internal processes against regulatory guidelines to identify opportunities for improvement. Regulatory surveys are valuable evaluation tools, but we have a deliberate focus on the quality and safety of our patients’ care every day.”

The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. Approximately 77 percent of the nation’s hospitals are accredited by The Joint Commission.

May 3, 2017

On May 1, 2017, surveyors from The Joint Commission arrived at Texas Children’s Hospital to conduct an unannounced 5-day survey to ensure that we are meeting the expectations of delivering the safest, high quality care to our patients and their families.

Every three years, Texas Children’s undergoes an accreditation process by the Joint Commission survey team to access the organization’s compliance in patient care areas that contribute to positive outcomes, and to measure and improve performance.

This week, surveyors will visit Texas Children’s Medical Center Campus, Pavilion for Women, West Campus, The Woodlands, ambulatory clinics, dialysis, and health centers to evaluate our patient care processes through a variety of measurement tools including on-site observations, staff interviews, and tracer methodology. Just this year, the Joint Commission implemented a new survey methodology called Survey Analysis for Evaluating Risk (SAFER), a matrix that uses a color-coded grid to evaluate the likelihood of harm to patients, staff and visitors based on the number of occurrences.

“Our first day of the survey went very well, with surveyors citing positive feedback in several of our patient care and safety protocols,” said Texas Children’s Quality and Safety Director Elaine Whaley. “Since these accreditation surveys are unannounced, preparing for the Joint Commission survey has been a crucial, on-going and continuous process for our employees and staff.”

Next week, Connect will have an article with an overview of this week’s survey.

The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. Approximately 77 percent of the nation’s hospitals are accredited by The Joint Commission.

May 27, 2014

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Texas Children’s recently received an impressive report card from The Joint Commission with surveyors commending the hospital for demonstrating several best practices.

“Our survey results are a great indication that we are meeting the expectation of quality care for our patients,” said Texas Children’s President and CEO Mark A. Wallace. “This should only propel us to continue our focus on providing safe, quality care every single day for every one of our patients.”

Every three years, Texas Children’s undergoes an accreditation process by The Joint Commission survey team to ensure our delivery of high-quality patient care. Five surveyors arrived at Texas Children’s for a five-day survey on May 12. The survey team included a pediatrician for inpatient areas and the medical staff, and another pediatrician for ambulatory areas, an Ob/Gyn specialized nurse, pediatric nurse and a life safety engineer.

What Joint Commission noted

The survey is intended to assess the organization’s compliance in patient care areas that contribute to positive outcomes and to measure and improve performance. The Joint Commission team was very impressed with our improved outcomes in asthma, diabetes, radiology efficiency and flow, patient flow and surgical complications. The team also identified several best practices observed during the survey, including:

  • Time out processes across the system
  • Error prevention technology in the anesthesia ad pharmacy areas
  • Use of data to improve patient outcomes

“The Joint Commission survey team visited several Texas Children’s facilities to evaluate patient care processes through on-site observations, interviews and tracer methodology,” said Mary Jo Andre, Texas Children’s senior vice president of Quality and Safety. “Surveyors use tracer methodology to retrace the specific care processes that a patient experienced by observing and talking to staff in areas where the child received care.

“The surveyors were very impressed with the knowledge and confidence of the staff and faculty who participated in the tracer interviews. They complimented them also on their ability to navigate Epic and explain the continuum of care. Most importantly they were impressed with their ability to talk about quality projects and outcomes. We are very proud of their performance.”

How we prepared for the survey

Preparing for regulatory surveys is an ongoing process underscored by Texas Children’s daily focus on patient safety and high quality programs. About six months before our anticipated Joint Commission survey, Texas Children’s hires a consultant to review our processes and evaluate our survey readiness. The information provided by the consultant helps the organization fine tune.

“The results we get from area tracers during that preparation process provide information we need to develop and implement an organization-wide readiness education program,” said Trudy Leidich, Texas Children’s director of Quality and Safety and Medical Staff Services. “But we regularly evaluate our internal processes against regulatory guidelines to identify opportunities for improvement. Regulatory surveys are valuable evaluation tools, but we have a deliberate focus on the quality and safety of our patients’ care every day.”

An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 20,500 healthcare organizations and programs in the United States. Approximately 77 percent of the nation’s hospitals are accredited by The Joint Commission. Accreditation surveys are unannounced, so preparation is a crucial, on-going process.

“Accreditation by The Joint Commission means Texas Children’s meets the highest quality and safety standards in patient care,” Wallace said. “It gives patients peace of mind knowing that our facilities are surveyed routinely and that we meet or exceed a comprehensive assessment of the care we provide.”