Saint Raphael Campus readies for TJC; DPH will survey entire hospital

Tori Dahl Vickers (left), RN, MBA, director, Accreditation, Safety and Regulatory Affairs, recently did an environment-of-care tour on the Bone and Joint Center on the Saint Raphael Campus. She reviewed equipment and its readiness for use with Susan Fitzgerald (second from left), RN, Joy Burke-Hopkins, RN, and Alison Gaffney (right).
Tori Dahl Vickers (left), RN, MBA, director, Accreditation, Safety and Regulatory Affairs, recently did an environment-of-care tour on the Bone and Joint Center on the Saint Raphael Campus. She reviewed equipment and its readiness for use with Susan Fitzgerald (second from left), RN, Joy Burke-Hopkins, RN, and Alison Gaffney (right).

Editor's Note: When this story was sent to the printer, YNHH’s Saint Raphael Campus was expecting the extension surveyors from The Joint Commission. On February 20, TJC surveyors began to survey the campus, but it was too late to update the story.

Between now and this August, The Joint Commission (TJC) will conduct an extension survey on the Saint Raphael Campus — the first since it joined Yale-New Haven Hospital — and Connecticut's Department of Public Health (DPH) will survey the entire hospital.

The Joint Commission accredits healthcare organizations in the U.S. In addition to the SRC, it will conduct surveys of the Smilow Cancer Care Centers and the durable medical equipment section of The Boutique at Smilow. DPH will conduct a licensure survey of the entire hospital; DPH is expected by spring or early summer.

"Crucial to success with regulatory readiness and surveys are practices that become part of our daily routine — it becomes how we work," said Alison Gaffney, regulatory coordinator, Accreditation, Safety and Regulatory Affairs. "To help with preparation, we have developed a number of educational and informational tools that will help employees."

In the next week, managers will introduce a set of flash cards in huddles and staff meetings. The flash cards cover the broad topics that TJC surveyors will go over with staff when they survey the campus. The cards will provide questions — and answers — ranging from national patient safety goals to medication management that will help staff prepare for the mock surveys leading up to TJC survey.

In addition to a well-attended regulatory readiness fair on the SRC and the flash cards, the electronic newsletter FrontLine News continues to inform employees regularly about safety and regulatory issues. It provides valuable updates that keep issues top-of-mind for staff. It is available online and managers post FrontLine News on patient care units.

Gaffney notes that SRC clinical staff will soon receive a small spiral handbook that will fit easily in their pockets for quick reference. This book contains handy reminders on the proper use of restraints, pain management, and how to reduce patient falls.

"We have the tools to help employees prepare for The Joint Commission," said Gaffney. "We know TJC is coming any day to the SRC so preparation is absolutely crucial — you have to start it well before they walk through the doors!

"Our goal is to prepare a workforce that is confident and interacts effectively with the surveyors," said Gaffney. "We provide safe, high-quality care and the survey will give us the opportunity to tell them about the excellent work we do for patients."