The amount of time leading into a survey with The Joint Commission (TJC) can seem endless. It’s akin to preparing for a long journey where you check, validate, re-check, adjust, and continually inspect your working environment. While we endeavor to be TJC prepared every day, we all wear a hyper focused lens as the survey date approaches. As you tick off months and weeks, TJC suddenly appears and you feel a sense of both relief and anxiety as the survey begins. Years ago, the role of IT was to essentially hide from the surveyors by staying out of site. As long as the data center was free of boxes, power strips had been checked for medical grade, and everyone had on their badge to know the codes and fire safety information, IT was safe. The techs could dash from service ticket to service ticket with relative obscurity and leadership had to be on-deck to answer questions about data continuity and recovery.
Having survived two previous surveys with varying degrees of outcomes, two realities are before us today. During our survey completed this past month, a kinder and gentler Joint Commission has emerged and IT is no longer in the shadows.
The Joint Commission has spent much of the past five years branding themselves as a collaborative agency versus a punitive one. They strive to take the fear out of a one-way dissertation of what you don’t do well and turn it onto a conversation about opportunities to improve the delivery of quality patient care. The surveyors who spent a full five days with us exhibited both a true desire for comprehensive explanations as to what they were specifically looking for and how they expected to see it. Coaching and conversation occurred during each daily opening session, throughout tracers, and at end of day summaries.
Each interaction included open dialogue featuring individual kudos for exemplary staff, areas of opportunity and improvement, and summaries of what we should continue to do in the way of best practice and standards. This is a refreshing approach to an industry staple and requirement.
Let’s be honest, it’s not all unicorns and rainbows during a survey. The Joint Commission finds the things you expected as well the ones they shouldn’t have after all your preparation. It’s one thing receive improvement feedback on care plan management (which is appreciated) and another to get dinged for full and empty oxygen bottles cohabitating (which is frustrating since we clearly know better).
You may be reading this thinking I am crazy to be energized by a recent survey.
In fact, our system had a fantastic survey with a finite number of opportunities all directed towards areas we already have on our strategic and operational plans. We knew our opportunities for improvement going into the survey. From conversations with TJC, we have input and feedback that we are on the right path and the journey to get there.
Our survey was fantastic due to focused and deliberate preparation as well as the years of exceptional leadership and vision carried by Allen S. Weiss, M.D., our President and CEO. He has created a culture where employees are lauded and rewarded for providing phenomenal patient care. He knows everyone by name, sends them hand written cards, walks the halls at all hours of the day and night, and is genuinely a kind leader. He is also a top physician and a brilliant thinker. His persona trickles into every level of the organization and it is evident in the many awards, accreditations, and recognitions the system continually receives. When it comes to the role of IT, his passion is equally evident. He is a co-founder of Cerner ITWorks, and the role of IT in the organization and during our recent survey was central to our success.
30 minutes of uninterrupted time with The Joint Commission.
As the CIO I was thrilled at the opportunity to share IT with our surveyors. All week we had been discussing standardization, documentation, analytics, reporting, and system solutions. They shared areas where they recommended software to improve process (tissue tracking and policy management) as well as continuous monitoring applications for temperature control. Check – these were on our recommended roadmap and will be both approved and fast tracked – a plus for the IT team. The real validation came from the wrap-up on the final day where I had 30 minutes of dedicated time with the surveyors during the leadership conversation to share the disciplines, strategy, and foundations of running team filled with high-performing and high-potential professionals.
Predictable, repeatable, and consistent processes.
IT is a service organization with the privilege of contributing to the care of patients. As an ITWorks shop, we have co-branded ourselves with Cerner. Our customers know that to deliver predictable, repeatable, and consistent processes, we must always anticipate, innovate and accelerate. It’s about understanding where we want to be and how we get there. As we grow into a multi-faceted system of care, we have specific goals in how we perform and improve upon the work we do to support the mission and vision of the organization.
Framework dedicated to these disciplines:
- Applications – Department alignments are a core component of ensuring we are in lock step with those we serve. Each member of IT has dedicated departments they strategically meet with up to twice per month in additional to the day to day interaction.
- Infrastructure – Our goal is to keep infrastructure two steps ahead of the roadmap for the system so we can meet the growing needs of the organization. We never want IT to hold up progress.
- Project Management – A multi-disciplinary committee steers governance and throughput. It is essential we can measure and deliver the right projects at the right time and on budget.
- Informatics – Clinical and business analysis for continuity, shared decision making, and adaptability is paramount. Regulatory compliance is everywhere and we must be able to achieve it seamlessly.
- Security – Our responsibility to protect our patients, our people, and our business is absolute. We make this known to everyone while partnering to make it happen system wide.
- Leadership – Our core component for engagement that is shared through active and focused succession planning, development, and the tenant that to succeed as a total unit, none us is as smart as all of us.
Strategic alignment for key system deliverables:
- Population Health – Delivering new approaches to managing our patients with dynamic registries in the context of care via process and innovation driven back into the workflow versus the traditional PMPM analysis route.
- Integrated Clinical & Financial Systems – Connecting across the continuum of care with click reduction, specialty play books, and standardization. Once disparate systems such as ambulatory and revenue cycle are becoming fully integrated systems.
- Patient Engagement – Today patients want to own their data have input into how it is managed. The foundations of Commonwell along with enhanced methods of sharing data and outcomes put more informed choices into the hands of the consumer.
- Physician & Clinician Experience – Building intelligence into systems for optimal care should be a positive experience. Applications that work as designed due to fine tuning that also allow for patient engagement during the encounter.
- Security – Balancing confidentiality, integrity and availability. Ensuring everyone involved in patient care and business operations has adequate and accurate information delivered in a timely and secure fashion.
Foundation of collaboration, communication, and industry best practices
Ensuring we have the pulse on these keeps us relevant and focused on continuous education. There is so much coming at us all the time, we bring the information forward to the entire team via monthly All Hands, weekly newsletters, blogs, book clubs, webinars, vendor education sessions and involvement in professional associations. Top alignment includes active involvement in HIMSS, CHIME, CHC, ACHE, NAPW, AEHIX, and Advisory Board. Encouraging team members to extend their reach beyond the scope of the system is a differentiator for us in our ability to connect with our customers.
The timing of TJC survey could not have been more opportune. The team and I have been together for less than a year and it has been a year of learning and aligning as we embark upon a robust agenda for the future. It was a validation of our efforts and the passionate and personal nature of the work we perform every day. IT was given accolades, suggestions for development, and areas of continued focus.
It was feedback we welcomed and did not necessarily expect. The Joint Commission was impressed with our vision and strategy. One member even said he’d like to work on our team! While TJC certainly continues to be an organization with a big stick, they wield their power and influence carrying a much larger carrot. The role of IT in the process is a welcome and forward-thinking inclusion.
Have you recently had a survey or are you anxiously awaiting the arrival of your surveyors? Please share your thoughts with me at www.conciergeleadership.com, email@example.com, or @conciergeleader.