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Mission: Achieve continual readiness for Joint Commission surveys


It’s 8:30 A.M. Monday, and the hospital is bustling. The operating room has a heavy schedule. Six emergency-department patients have been admitted and await open beds. All of a sudden, you hear “Code J” announced over the PA system—and the nightmare begins. The nurse manager on 2-North starts barking orders to her staff. “Peter, clear the hallways and hide the Christmas decorations in the storage room. Julie, make sure our I.V. sites and irrigation sets are dated. Cathy, check the charts and see if all our patients have up-to-date care plans and discharge plans.”

The charge nurse scrambles to verify that the crash cart logs and refrigerator logs have been completed. “Oh my gosh!” she suddenly exclaims. “Who took the refrigerator thermometer? And where did all this old food come from?”

Meanwhile, the nurse manager heads for the medication room to check drug expiration dates. She finds the medication cabinets unlocked and sees donuts and spilled coffee on the counter. Taking a deep breath to calm herself, she opens the cupboard under the sink. There she spots unit supplies, a box of cookies, and staff members’ purses. No amount of deep breathing can prevent her from losing her cool now!

Most of you can relate to this tale of a surprise Joint Commission (JC) visit. It could happen on any nursing unit on any given day. Meeting the myriad standards and regulations established for healthcare facilities by federal, state, and local agencies can be challenging enough. Keeping staff members in continual readiness for an unannounced survey may seem nearly impossible.

Yet being in a continual state of readiness diminishes the stress of last-minute preparations. This article describes how nurse leaders can make sure their staffs are perpetually prepared—and confident—for surprise surveys.

JC’s survey approach

In 2004, the JC rolled out a new survey approach: Their surveyors now spend more time reviewing patient-care activities, processes, and outcomes by using “tracer” methods and talking with staff members involved in direct patient care. Tracer surveyors trace the care processes patients experience during the continuum of their hospital stays and discuss standards with the care providers closest to the patient situation.

In 2006, JC began its unannounced survey process, in which facilities don’t have the luxury of preparing for surveys. Long gone are the days when JC surveyors sat in a hospital’s conference room all day reviewing manuals, committee minutes, and closed patient records. Now they spend less time on document review and more time discussing effective care with clinicians.

Many healthcare organizations have created teams linked to each JC standard of care. The teams conduct gap analysis and develop performance improvement plans for organizational readiness related to the assigned standard. This strategy promotes a systems-oriented approach to process improvement and quality outcomes. Unit leaders and staff members are responsible for implementing the teams’ recommendations and conducting unit-based initiatives to ensure high-quality care at the unit level.

Developing a culture of readiness

Continual quality improvement is a way of being, not just a periodic activity. If employees merely try to get through a survey using scripted responses, they may perceive that the survey and their participation in it have little value to themselves or their patients—an attitude not conducive to feeling engaged in the process.

Instead, nurse leaders and the shared governance committee of the nursing unit must set standards for, and promote conditions that foster, a culture of safety, quality, and readiness. The focus needs to shift from merely doing what’s needed to meet requirements, to ensuring continual performance and process improvement.

Using the “E” approach

To achieve a culture of continual readiness for surveys, try using what I call the “E” approach. It assigns activities to four categories starting with the letter E—expectations, education, engagement, and evaluation.


Leaders of each nursing unit must be clear about their expectations for staff members. They must spell out the unit’s mission, vision, and goals (which should support the overall goals of the nursing department and organization). The unit’s quality initiatives must align not just with these goals but with established best practices, as delineated in such resources as:

  • JC’s National Patient Safety Goals
  • evidence-based clinical practice guidelines from the Agency for Healthcare Research and Quality
  • quality measures from the Centers for Medicare & Medicaid (CMS)
  • safe medication practices from the Institute of Medicine and Institute for Safe Medication Practices
  • nursing-sensitive indicators from the American Nurses Association.

Unit leaders must stay current on these organizations’ standards, databases, and measurement tools for quality monitoring. They must incorporate the expectation for meeting standards in everyday interactions with their staff and when evaluating care processes and outcomes on their units. As a leader, you need to set the stage for safety and quality. You must “walk the talk” every day.


Staff members should be educated on quality initiatives and unit-based outcomes on a continual basis. Such education should focus on standards of care and error avoidance, and should be delivered in a way that emphasizes systems rather than casts blame and metes out punishment.

The following educational strategies have worked for many nursing units and departments:

    • “Quality care” is a standing agenda item at monthly meetings to ensure that quality-related issues, current performance, and improvements are discussed.
    • Unit-based shared governance councils focus on quality initiatives and share updates at unit meetings. Decision making centers on patient safety and quality of care.
    • Unit bulletin boards have a designated “Quality Corner” where staff members post nursing report cards, performance improvement plans, patient satisfaction data, and pertinent graphs.
    • Unit leaders take advantage of informal “teachable moments.” When making rounds, for instance, they look for evidence of quality as well as evidence that standards aren’t being followed. Providing frequent constructive feedback and giving kudos where due are crucial and effective.
    • Units partner with other hospital units or departments to provide in-service sessions for staff. For example, a pharmacist provides insight into safe medication practices, an infection-control practitioner discusses how to prevent nosocomial infections, and a quality management/utilization review specialist presents data on CMS quality measures, length of stay, readmission, and utilization.


Staff members can provide high-quality care and maintain continual readiness only if they’re engaged and working together as a team. Nurses have a professional responsibility to be safe practitioners and keep their knowledge and competencies up to date through continual education and participation in professional practice decisions. Environments that empower nurses and give them some control over their practice contribute to improved quality and patient safety. Creating a safe culture where nurses feel empowered also promotes interdisciplinary dialogue that can help identify important issues and barriers to success.

All staff members must play a role in quality initiatives. Such roles may include assigned activities—for instance, safe-environment checks, chart reviews, purposeful patient rounds, performance-improvement data collection, committee participation, and sharing with colleagues.

In addition, all staff members (including unlicensed assistive personnel) should be included in unit readiness. Patient-care technicians, certified nurse assistants, and unit secretaries can help monitor, correct, and report on environmental safety, as by keeping halls and storage areas clear, keeping patient rooms tidy, logging refrigerator and freezer temperatures, and covering linen carts. These activities should be assigned, not assumed.

Using a monthly signup sheet, registered nurses and licensed practical/vocational nurses can sign up to give updates for the “quality care” agenda item during meetings. (See Sample signup sheet for quality-care topics by clicking on the pdf icon above.) Let staff members know you expect every nurse to participate. Such participation increases nurses’ engagement in comparing their unit’s performance to benchmarks.


Evaluation is most effective when conducted concurrently rather than retrospectively, so that feedback can be given to staff members and changes implemented where necessary. I can’t overemphasize the importance of giving positive feedback, ranging from a pat on the back to formal recognition. Everyone wants to be recognized for a job well done. Handwritten notes, letters placed in employee files with copies sent to appropriate administrators, and small tokens of appreciation (such as gift certificates to the coffee shop) go a long way toward recognizing and rewarding good performance. Many organizations have peer-recognition activities that include thank-you-note bulletin boards where staff members post appreciation notes to each other.

When necessary, leaders should provide constructive criticism in a timely fashion. Along with such criticism, reinforce your expectations for the employee. If a staff member fails to meet these expectations, convey this conclusion honestly in a structured performance appraisal. (The same goes when an employee meets or exceeds expectations.) Use your organization’s performance management policies to address the deficiency. Don’t sweep poor performance under the rug or simply transfer it to another department.

In addition, invite representatives of other departments to visit your unit so they can provide information on their care processes and outcomes and help staff members see how the various disciplines can work better together to improve patient care.

Finally, participate in mock tracer studies to aid assessment, using leaders from other departments who can assess your unit’s processes objectively. This also helps prepare staff to feel comfortable discussing patient care processes and outcomes with others.

A final “E” for excellence

Setting clear expectations, providing staff education, engaging staff in quality initiatives, and evaluating outcomes can help your work culture achieve both continual readiness for surveys and excellence in performance. A culture of excellence empowers nurses to create innovative solutions to help achieve excellent clinical outcomes, which in turn supports the Magnet™ principles of the American Nurses Credentialing Center. Magnet hospitals demonstrate better quality, as shown by decreased patient morbidity and mortality. By maintaining a laser focus on high standards of patient care, leaders and their staff can help ensure their units are complying with regulatory requirements and are supporting a culture that demonstrates Magnet principles in daily practice.

Consistently providing the safest and best care possible isn’t negotiable—but being in continual compliance isn’t as daunting as it may seem. You can achieve this goal by exhibiting visionary leadership, creating a culture of safety and high expectations, and using effective communication, education, feedback, and teamwork.

Selected references

Adamski P. Implement a handoff communications approach. Nurs Manage. 2007;38(1):10,12.

Adamski P. Prepare for the next patient instead of the next survey. Nurs Manage. 2006;37(11):9.

American Nurses Credentialing Center. Announcing a New Model for ANCC’s Magnet Recognition Program. www.nursecredentialing.org/
Magnet/NewMagnetModel.aspx. Accessed August 24, 2009.

Comeau E, Lowry D. Unannounced JC survey. J Nurs Care Qual. 2005;20(1):5-8.

Gant NR, Sorenson L, Howard RI. A collaborative perspective on nursing leadership in quality improvement. Nurs Adm Q. 2003;27(4):324-329.

Barbara C. Sorbello is Administrative Director for Acute Care Services at Bon Secours-St. Francis Medical Center in Midlothian, Virginia.

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