Westfields Hospital and Clinic

Becoming accredited by The Joint Commission was the next logical step in our on-going performance improvement journey. It’s recognized by others as validation of a higher standard and provides tools and best practice benchmarks to help us sustain and elevate the quality and safety of care we provide. Supporting us on our accreditation goal was the Westfields Hospital & Clinic Board of Directors and other HealthPartners hospitals. The Westfields Board of Directors and senior leadership team was committed to the accreditation process from the start and set the tone for all of us that this was important. We established an accreditation committee and used our robust process improvement tools to drive implementation.

We identified chapter leads and began monthly meetings with them to check on progress. We learned early on that it was extremely important to work on accountability. Everyone has other work to do and is busy, so making the Joint Commission preparedness work a priority was important. We also made sure to explain why we were doing things – not because The Joint Commission says so. We didn’t want the prep process to feel like a burden; we wanted it to be about doing the right things in the right way for our patients. That really resonated with our staff. We conducted tracers in patient care and the environment of care using real timelines to mirror an actual survey.

The actual survey was interesting, especially when the surveyor shared best practices on how to prepare for a survey from other organizations and pointed out unique things we had done. One of the best practices identified was the use of flash cards that we developed. These flash cards helped teams prepare for frequently asked questions everyone should know. It was fun to see our staff – both clinical and those who do not provide direct patient care – quiz each other in preparation. About eight days after the survey, the state came in to do their survey and we were ready!

In addition to enhancing our performance improvement practices, and increasing our discipline, accountability, and sense of pride, preparing for Joint Commission accreditation helped us on our path to becoming a high reliability organization. We’ve done a lot of work on process improvement. We use the LEAN tools to move our improvements forward. We’ve used The Joint Commission’s “Leading the Way to Zero” video during leadership sessions to help set the stage. We’ve even increased our safety event reporting after making it clear that these events are important to learn from and can help us do better.

From our perspective:

• Take advantage of available resources. The survey activity guide was helpful, as well as The Joint Commission Big Book of Checklists and mock tracer materials. Consider education programs, which really helped us prepare for the entire process.
• Utilize your Joint Commission account executive – ours was very helpful answering questions and making suggestions.
• Make sure senior leadership is engaged in the process – that way they can lead by example and hold the staff accountable.
• Accept that you will be learning as you go. A lot of the standards are probably things you’re already doing, and you will just be learning how to do it a little differently and a little better. Keep an open mind!
• Don’t apply until you’re ready.
• Tie everything you do back to the benefit to the patient. This is the best motivation for everyone involved.