How does one of the country’s largest hospitals prepare for accreditation and licensure surveys when faced with multiple competing priorities?
“You know how to eat an elephant, right?” asked David Depukat, RN, director, Accreditation and Regulatory Affairs. “One bite at a time.”
The hospital is getting back to basics to ensure the “house” is in order for unannounced site surveys from the Connecticut Department of Public Health (DPH) and The Joint Commission.
“We’re calling it the ‘Big Spring Clean,’” Depukat said. “This is a planned, measured effort to clean, remove clutter and review processes to ensure continued attention to the environment. First, we’re taking one focus area at a time across inpatient, ambulatory, clinical and non-clinical areas that can be reviewed by The Joint Commission.”
Hospitals in Connecticut are required to be licensed by DPH. Joint Commission accreditation is required to receive Medicare and Medicaid certification so the hospital can treat these growing patient populations.
DPH surveyors could arrive any day now as YNHH’s license expires in September 2025. The Joint Commission surveyors are expected anytime between this September and next February. Inspections typically look for compliance with regulations related to areas such as facilities, medical records, policies and procedures, infection control, safety and quality.
In March, the hospital invited Joint Commission Resources to conduct a full simulation survey, which is like a test run to see what we’re doing well and where we may need to improve. The feedback proved valuable. Overall, surveyors found staff to be very engaged, welcoming and in lockstep with the principles of a High Reliability Organization.
“We know we are remarkably good at getting things done when we are all aligned on our goals and objectives. The challenge is sustaining the improvements we have made,” said Victoria Dahl Vickers, vice president, Accreditation and Regulatory Affairs.
YNHH President Katherine Heilpern, MD, agreed. “We are doing so many things right, but the Big Spring Clean will re-energize and re-focus us so that we work to achieve and maintain top-tier performance with respect to disinfection practices, cleanliness and clinical care.”
Each week features a different Big Spring Clean theme for action, such as looking for damaged ceiling tiles, along with instructions on how to report items and get them fixed. The regulatory team will keep an inventory of reported items and triage them for repair or other action. Managers will also receive “Clean Sweep” toolkits and resources, and senior leaders will round in areas every week. Staff are encouraged to share tips, best practices and before-and-after photos by sending an email to [email protected].
“By focusing on one area each week, we’re taking a bite of that proverbial elephant a little at a time,” Depukat noted. “We are making what seems like a daunting, enormous task for one person much more manageable. Our collective efforts will be cumulative, and we will see results.”
“The work associated with the Big Spring Clean also will help us shift our mindset and actions to one of everyday readiness – not just Joint Commission readiness,” Dr. Heilpern said. “We will benefit from a daily proactive approach to quality, safety and performance improvement.”
