“Continuous readiness” keeps YNHHS prepared for regulatory surveys

Yale New Haven Hospital is expecting The Joint Commission (TJC) to arrive unannounced this late fall or early winter for the triennial accreditation survey to measure hospital performance. Achieving accreditation is a seal of approval that indicates a hospital has met or exceeds TJC performance standards. 

“Our success will depend upon staff demonstrating, articulating and documenting our safety and quality practices,” said Victoria Dahl Vickers, RN, vice president, Yale New Haven Health Accreditation and Regulatory Affairs. “Safety and quality practices that become habitual parts of our daily routine and how we care for our patients are crucial to our success with regulatory preparedness and surveys.”

The health system’s Accreditation and Regulatory Affairs (ARA) department is redefining its approach to continuous regulatory readiness. The department is moving beyond survey preparedness, which historically involved distributing pocket guides and educational material in anticipation of TJC triennial surveys. ARA is shifting its focus to engaging teams and staff in ongoing continuous regulatory readiness. 

“Our goal is to prepare a workforce that is confident and interacts effectively with surveyors,” said David Depukat, RN, director, Accreditation and Regulatory Affairs. “We provide safe, high-quality care, and surveys will give us the opportunity to demonstrate the excellent work we do for our patients.”

Over the next several months, ARA will launch a strategic continuous readiness plan that includes educational materials and tools for managers and staff to help employees with ongoing regulatory readiness. 

ARA has implemented focus areas addressing opportunities for improvement in both the short term and long term, with an emphasis on sustainable improvement and monitoring.  

ARA is implementing a targeted communication approach for high-risk, common findings that includes: 

• Safety Matters tips sheets available from the ARA intranet page. These focus on topics that TJC and state surveyors will review with staff during hospital surveys. Managers, assistant managers, outcomes leaders, educators and safety specialists are encouraged to use and share these tips sheets at huddles and staff meetings. More resources will be added in the coming months.
• NetPresenter slides will begin displaying regulatory-focused topics, such as National Patient Safety Goals, life safety and medication management. These slides will provide important updates that keep issues top-of-mind for staff and reinforce safe practices.
• Accreditation and regulatory specialists rounding on units will help prepare the environment of care and clinical practices, addressing department-specific concerns. 
• “Foundations of Regulatory, Safety, and Performance Improvement” virtual training sessions will be available through YNHHS’ Institute for Excellence. Other regulatory sessions are provided for nurse and nurse manager residency programs. 

Please contact your regulatory liaison, or call 203-688-6374 if you have questions, concerns, need help locating resources on the intranet or would like to schedule rounding sessions.