From left: Wanda Ramos and Lauren Mazzone review readiness tips for the upcoming Joint Commission survey.

For a moment during the Joint Commission Staff Readiness Fair last week, Lauren Mazzone, MBA, paused and looked around Cabot Atrium, admiring her peers as they educated each other about the work they do each day to improve patient care and safety at the Brigham.

“It was great to see staff from various roles and areas across the hospital stopping by the readiness fair,” said Mazzone, program manager in Clinical Compliance. “In many instances, folks shared something new they had learned from visiting the different departments’ tables, which is fantastic. The feedback we received about the fair during and after the event reiterated to us that we’re all in it together.”

Between now and January 2019, The Joint Commission (TJC) surveyors are expected to arrive at BWH to conduct a hospital-wide accreditation survey. TJC, which accredits the Brigham every three years, is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. The survey is conducted through the tracer methodology, a means of evaluation in which surveyors select a patient and use that individual’s record as a roadmap to assess an organization’s compliance with certain standards and its systems of care and services. The visit to the Brigham will include observation, medical record review and interviews with staff. In addition, an engineer from TJC will examine the environment of care and fire safety standards.

In preparation for the visit, BWH’s Clinical Compliance team held a staff readiness fair in Cabot Atrium on Sept. 13, enabling champions from various departments to educate staff about their work and offer TJC preparedness tips. Among the many departments with information tables at the event were Ambulatory Services, Biomedical Engineering, the Bretholtz Center for Patients and Families, Environmental Affairs, Engineering, Food Services, Health Information Services, Patient Safety, Privacy, and Police, Security and Commuter Services.

Kelly Doorley, MS, RN, director of Clinical Compliance, said she was thrilled with the strong turnout at the fair. She added that the Brigham’s upcoming TJC survey is an opportunity to demonstrate the institution’s commitment to delivering safe, high-quality care every day.

Doorley emphasized that all staff play a role in keeping patients safe. To prepare for the TJC visit, she suggested that BWHers remain focused on the basics, including always wearing your ID badge; knowing where emergency equipment is located; understanding your role during any emergency code or drill; and practicing hand hygiene before and after every patient interaction.

‘Readiness Is Our Responsibility’

Beth Baldwin, MSN, MHA, RN, program director in Nursing Informatics, said she decided to attend the fair to better understand how she can prepare for the survey. In addition to overarching tips, she appreciated the opportunity to learn more about proper responses to specific situations, such as how to access a locked bathroom in the event of a patient emergency.

“This, and the other tips and tricks the teams reviewed at the readiness fair, help me feel more prepared to talk with surveyors when they are on site. It’s our responsibility to patients, their families and each other to be compliant every day.”

Jon Boyer, ScD, CIH, director of Environmental Affairs, said his team is committed to working with BWH staff to develop creative solutions to the Brigham’s complex safety, health and environmental compliance requirements.

Now through Sept. 28, Environmental Affairs is hosting a “Safety Selfie Challenge” in which staff are encouraged to take a selfie in three safe situations and submit them for a chance to win a prize. Any photos with patients must have proper consent, and staff must be mindful of private information that could inadvertently appear in the background.

“When we work together, safety can be fun,” Boyer said. “It’s everyone’s job to help keep our clinical, research, support and administrative spaces safe and compliant for patients, their families, visitors and staff at all times.”

Stephanie Peña, a service coordinator in the Center for Patients and Families, enjoyed the opportunity to ask questions and educate herself about the work of many other departments.

“It was a great chance to meet with people you speak with regularly by phone,” Peña said. “The readiness fair helped facilitate communication, which in turn will benefit all of us as we work to continuously improve patient safety and care at the Brigham.”

For more information about TJC readiness, visit