Infection Control Today - 07/2003: Add Flair to Your JCAHO Preparation

Add Flair to Your JCAHO Preparation

By Carolyn Ramsey, RN, MSN, CNOR

This article addresses the hubbub found just before a survey from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). We can say we shouldnt need any special preparation if were doing the right thing all the time, but as many of you know, that just isnt the case. Even though your hospital staff gives excellent patient care, there are always last-minute housekeeping, policy update, and maybe credential and competency updates to be accomplished before the big day.

During the last few years, JCAHO surveyors have changed the focus from administration to the staff caring for patients.

Members of the survey team are making rounds on nursing units and speaking with patients, families, nurses and ancillary staff. The author describes one way to get information to all the staff so they will be able to articulate the excellent care they do give. As we know, surveys will soon be unannounced, so ongoing refresher programs may need to be developed, and who knows? some of the stress of visits may decrease.


Joint Commission is coming. How can we make sure the staff is prepared and can intelligently answer their questions?

Most hospital employees have heard of JCAHO and since all employees are involved to some degree with the survey, preparation is a valid concern of administration.

It may be easy to say we give excellent care at all times, keep our policies updated, and all our staff have competencies completed, but there are always a few areas that may require further education or review. What is the best way to get information to the masses? We must remember that we are working with adult learners. To be the most effective, adult learning principles must be followed.

Lieb1 (1991) describes adult learner characteristics to be considered when planning a JCAHO review program:

  • Autonomous and self-directed They want to be involved in the learning process. Some of the participants should be involved in planning and development of the program.

They must also be shown how the information will help them.

  • Have life experiences and knowledge They need to connect learning to their own previous education. Educators should draw out the participants experience and knowledge by involving them in the presentation.
  • Are goal-oriented They must know the goal. Instructors should show participants how the program will help them attain their goals.
  • Relevancy-oriented They must realize the reason for learning something.

Instructors should use theories and concepts that relate to a familiar setting.

  • Practical Focus on information most useful to them in their work.
  • Want respect Instructors should respect the experiences of each of the participants. All staff should be treated as equal and be allowed to voice opinions.

All the adult learning principles should be considered when planning any type of review or education, especially for topics that involve all employees such as a JCAHO program. Because this must be required attendance for all, the participants should desire to attend. Incentives such as refreshments, decorations and anticipation of a fun learning experience all help insure participation. The time and dates of the offering should also be considered to include all shifts and weekends.

One way of offering fun and flair to an educational offering that also meets requirements for adult learners is a carnival-style presentation. All adults enjoy fun activities that can break the seriousness of a JCAHO visit, yet still give the information required to pass inspection.

Educators in a healthcare system planned the Carnival of Knowledge

program for their employees in preparation for their last JCAHO survey. The carnival atmosphere was created with balloons, ringmaster costumes, game show host imitations, and fortune tellers. There was a booth for various topics of learning including patient safety, competencies, age specific, cultural differences, the quality improvement process, and employee safety. Each person was given a sheet that was signed after attendance at each booth. For an added touch, each booth was given a different rubber stamp to use as a signature. It was faster than signing, and made for yet another fun benefit.

Infection Control

Infection control was stressed in many of the booths.

Patient safety was taught using the Jeopardy game format.

A computerized Power Point presentation using hyperlinks provided topics with questions and answers to infection control issues such as handwashing, patient identification in blood administration, and isolation policies and procedures.

Staff safety was stressed in a modified Match Game. Participants were required to match phrases with infection control, body mechanics, standard precautions and other safety topics. Groups divided into teams and raced to see which team could match the phrases first. At the completion, all the phrases were discussed so that all participants were exposed to the other teams information.

Many times questions and answers are developed to help employees remember the key information frequently requested by JCAHO surveyors.

Although the questions are useful references, the question and answer format can also be presented in a lighter form. At the same JCAHO Carnival, administrators served as the fortune tellers. Each participant visited the fortune teller and was asked a question from the list used to develop the reference booklet. The participant was required to answer the question drawn. As participants stood in line, they could also hear the questions asked, so several topics were covered.

Techniques for Retention

Adult learners respond better to a variety of teaching strategies. Use of auditory, visual, tactile and participatory teaching methods has been shown to help adult learners retain information. The carnival atmosphere provided all these stimulants. Visual components were the central tent that housed the fortune teller, colorful costumes and balloons at every booth.

Computerized video slides were also developed to display on a large screen at the front of the room. The slides contained short phrases related to JCAHO requirements, policy statements, and standard practices.

The slides were colorful and contained graphics and pictures. Each slide was on the screen about 20 seconds to allow time to read the information. The show was looped to play automatically with varied transition between slides, adding more interest. The addition of graphics and motion assisted in the retention of the information.

Adults learn better when not required to sit in one place for long periods of time. The carnival format allowed participants to move from booth to booth after 10-20 minutes. At the booth, chairs were provided to prevent fatigue from standing. The participants were constantly moving around. Just the association of the booth location, decorations and content provided stimuli to help participants remember the material presented.

Adults relate to previously learned information and experiences.

Single concepts with focus on the day-to-day application of the concept and practical applications help participants retain the information.

Frequent summary also increases retention and recall. The carnival format is an excellent means to introduce single concepts with frequent summary. During the 10-20 minutes spent at the booth, information is presented, related to practice and reviewed.

Further review was available in the booklet each participant received, as well as the fortune teller questions and the slide show information.

In a news release by JCAHO, the announcement was made that the intent by the Board of Commissioners was to transition to unannounced survey visits beginning in January 2006. Up to 100 hospitals have volunteered to participate in the first pilot testing of the unannounced survey process during 2004.

All hospitals strive to deliver quality patient care at all times. Unannounced surveys give hospital staff an opportunity to showcase the care given at any time. Perhaps the panic and last-minute attention to issues that should have been addressed at an earlier time will vanish.

What a concept a JCAHO visit as just another day in the life of healthcare institutions.

Carolyn A. Ramsey, RN, MSN, CNOR, is staff development educator for Trinity Mother Frances Hospital in Tyler, Texas.

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