Nursing Leadership: What I Wish I’d Known Part 3


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Introduction to Debby A Renner:

Debby is one of our valued Interim Chief Nursing Officers who has worked for HTS3-Executive and Interim Recruiting for over a year. As a “permanent” interim nursing executive, Debby is equipped with a range of experience spanning stand-alone acute care to multi-facility/multi-state organizations, as well as the state prison system. Her key focus areas have been on patient safety, policy and procedure development, and staff training.

“Debby is a very knowledgeable and experienced nurse leader who was immersed in a difficult and challenging situation. She skillfully engaged staff and provided candid recommendations for improvement. I highly recommend her,” – testimonial from a previous HTS3 Executive Recruiting CNO.

We are pleased to publish Part 3 in Debby’s multiple part-series blog where she shares first-hand experience as a leader in the workplace.

Accreditation Surveys And Patient Safety

Years ago, when I took on my first job as a staff nurse, surveys by the Joint Commission for the Accreditation of Healthcare Organizations or JCAHO (as it was known in 2007 changing its name to the Joint Commission or JC) were scheduled well in advance. During the time between surveys patient care remained in status quo.  Shortly before the survey was scheduled to occur, panic set in with a flurry of activity. At that time, JC allowed the hospital to select the patients whose care was going to be reviewed, thus the hospital retained a significant amount of control over the survey by what was presented to JC.  My leaders at the time were unable or unwilling to articulate the patient safety function of surveys, instead choosing to say “we have to, JC makes us.”

In 2004, JC changed their survey method to tracer methodology, a methodology which other accrediting bodies have adopted.  A patient’s record is randomly selected by the surveyor and can be selected at any point in the patient’s care. The surveyor can then, at any time, “trace” both the patient’s care and the organization’s compliance against JC standards throughout the system.

Irrespective of whether an organization chooses JC accreditation, another accrediting organization, or simply chooses to be surveyed by their state’s health department (as a proxy for Centers for Medicare and Medicaid Services or CMS compliance), it is mandatory for us as leaders to realize and articulate to our staff that these accrediting bodies’ goals should be aligned to ours – PATIENT SAFETY.

In my initial blog I discussed policies and procedures.  Meeting accrediting body standards starts with a clear understanding that patient safety is central to our healthcare mission and that policies and procedures are the foundation for patient safety.

It is imperative that policies and procedures not only be reviewed and updated on a regular basis, but must also reflect evidence-based practice.  In 2015, within three days of starting an interim nursing leadership contract, an issue arose and, as I researched the organization’s policies and procedures, I had several startling revelations.

Policies and Procedures Go Awry

First, all of the organization’s policies and procedures were outdated, having not been reviewed or revised since their implementation in the late 1980’s!    Many of the policies and procedures were quite literally one item, one-line policies.   No policies and procedures had been retired; rather, new policies and procedures had simply been added, leaving the organization with contradictory policies and procedures. Staff did not have clear guidance and patient safety was at high risk.  Additionally, policies and procedures were not easily accessible for the bedside staff. Although the organization had an EMR and each nurse had a workstation on wheels, there was no online access to policies and procedures; instead, they were locked in the manager’s office.  During my career I have seen one organization after the other relegate policy and procedure creation, review, and revision to the nuisance category and being completely ignored until crises arise.

The organization had no system or timeframe for policy and procedure review.  How these outdated policies and procedures escaped the notice of the accrediting body I am unsure.  The emergent remedy was for each unit to create, within 48 hours, an integrated and combined document for each unit — a scope of service/standards of care.  On the medical/surgical unit alone this scope of service/standards of care document allowed the retirement of a significant number of policies and procedures.  Shortly thereafter a systematic review of ready-made policy and procedure resources was undertaken and a product was selected and procured immediately.

As an added benefit, the scope of service/standards of care document worked well for new employees and their orientation as well as providing a succinct overview of the unit to any agency staff.  These vulnerable staff now had a primer for the unit; the types of patients served and medical conditions they could expect to treat on that unit; and, perhaps more importantly, the standard of care patients, families, and physicians can/should expect.

The Impact of Current Policies and Procedures

 For the long term, organizations must articulate and operationalize policies and procedures as a high priority and integral part of patient safety.  Therefore, organizations must develop, implement, and maintain a systematic review of all policies and procedures in a manner that satisfies regulatory agency requirements and involves bedside staff input to enhance patient safety.   Policies and procedures must reflect evidence-based practice, state-of-the-art science of patient care, and be referenced.

In the age of immediate online resources, one of the most important policies and procedures that must be included by organizations is guidelines for staff on actions that need to be taken when there is no prescribed policy and procedure. This policy and procedure must also stipulate what the organization considers legitimate references found on the internet, which internet resources that the organization does not recognize, and how to document what guided their care in this, the odd patient care situation.

Policies and procedures have to be easily and immediately accessible to all staff. The vast majority of our patient care documentation is computer based; therefore, keeping policies and procedures current and immediately available to all staff should be relatively easy to accomplish with a short-cut icon and ability to print.   Only one hard copy of policies and procedures document should be kept and it must be current at all times.

Updated and relevant policies and procedures assist the organization in guiding and supporting the staff in successfully and seamlessly meeting the requirements of accreditation surveys.  For this reason, it is imperative that these policies and procedures support the accrediting body standards.  Additionally, encouraging the staff to continually align their daily practice to a survey readiness mindset makes accreditation surveys less stressful for everyone and enhances patient safety.  After all, this should be the standard practice within your organization.

As a leader, it is imperative to demonstrate your commitment to patient safety by guiding nurses and other clinical staff on how to embrace accrediting bodies as well as policies and procedures to create a rich culture of patient safety.