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 foundjust before a survey from the Joint Commission on Accreditation of HealthcareOrganizations (JCAHO). We can say we shouldnt need any special preparation ifwere doing the right thing all the time, but as many of you know, that justisnt the case. Even though your hospital staff gives excellent patient care,there are always last-minute housekeeping, policy update, and maybe credentialand competency updates to be accomplished before the big day.

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

Members of the survey team are making rounds onnursing 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 beable to articulate the excellent care they do give. As we know, surveys willsoon 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 surethe staff is prepared and can intelligently answer their questions?

Most hospital employees have heard of JCAHO andsince all employees are involved to some degree with the survey, preparation isa valid concern of administration.

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

Lieb1 (1991) describes adult learnercharacteristics 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 willhelp 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 thatrelate 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 beconsidered when planning any type of review or education, especially for topicsthat involve all employees such as a JCAHO program. Because this must berequired attendance for all, the participants should desire to attend.Incentives such as refreshments, decorations and anticipation of a fun learningexperience all help insure participation. The time and dates of the offeringshould also be considered to include all shifts and weekends.

One way of offering fun and flair to aneducational offering that also meets requirements for adult learners is acarnival-style presentation. All adults enjoy fun activities that can break theseriousness of a JCAHO visit, yet still give the information required to passinspection.

Educators in a healthcare system planned the Carnivalof Knowledge

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

Infection Control

Infection control was stressed in many of thebooths.

Patient safety was taught using the Jeopardygame format.

A computerized Power Point presentation usinghyperlinks provided topics with questions and answers to infection controlissues such as handwashing, patient identification in blood administration, andisolation policies and procedures.

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

Many times questions and answers are developed tohelp employees remember the key information frequently requested by JCAHOsurveyors.

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

Techniques for Retention

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

Computerized video slides were also developed todisplay on a large screen at the front of the room. The slides contained shortphrases related to JCAHO requirements, policy statements, and standardpractices.

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

Adults learn better when not required to sit inone place for long periods of time. The carnival format allowed participants tomove from booth to booth after 10-20 minutes. At the booth, chairs were providedto prevent fatigue from standing. The participants were constantly movingaround. Just the association of the booth location, decorations and contentprovided stimuli to help participants remember the material presented.

Adults relate to previously learned informationand experiences.

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

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

Further review was available in the booklet eachparticipant received, as well as the fortune teller questions and the slide showinformation.

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

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

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

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

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