Three Years in the Making: Success of Clinical Reviews

Many of us who have worked in healthcare over the years know the fire drill of "JACHO is coming". Typically, a facility will beef up on the standards six months in advance of the anticipated survey, creating chaos with new processes and paperwork. Then as soon as the survey is completed it's back to business as usual.

Regent took a hard look at this phenomenon in 2006, and made the decision to take an upstream proactive approach to consistent quality care versus a downstream knee jerk reaction to unplanned outcomes. In assessing the state of our current facilities it was noted that most facilities were not accredited and not consistently meeting required standards. Our clinical leaders were not equipped to manage the state, Medicare, and accreditation requirements.

We decided to jump in with both feet to create a lasting fix to the situation. Regent placed two Directors of Clinical Operations in the field. We also developed a '12 Step Program to Clinical Success'. This involves twelve intensive reviews designed to cover all known requirements for operating a quality healthcare facility. Every year we conduct a "mini survey" at each facility that covers all twelve areas.

Frequently programs that are implemented quickly die on the vine as they were not well thought out and are impossible to maintain. It has been three years since we began our clinical review program; now is an excellent time to reflect on its merit. Where are we today as a family of surgical hospitals and surgery centers?

Regent is proud to say that all of our facilities are now accredited. They are consistently passing the test of unannounced visits from the state, Medicare and accreditation agencies. We still experience angst when the call comes from a facility that they have a "visitor", but without fail our ASCs and Surgical Hospitals are excelling. During a recent JCAHO initial survey the surveyor commented how nice it was to be assigned to survey a Regent facility as he knew they would be ready.

The '12 Step Program to Clinical Success' has grown and flourished. We have developed a quarterly clinical quality scorecard to reward our DONs for a job well done, walking the talk of quality care. Regent sponsors an annual DON conference to offer ongoing education, training, and networking. These conferences have been received with great enthusiasm by the participants. We have also developed a standardized set of policies and procedures for both surgery centers and hospitals that are available on our corporate intranet. These documents aid the facility in taking the guess work out of the survey process. Confidence has replaced the chaos.

As healthcare providers we know that our responsibilities never end in meeting the challenges of providing an excellent outcome. We know that if we rest on our laurels we will be passed by in the flurry of progress. Strong goals have been set by our Directors of Clinical Operations for 2010. Our facilities can look forward to continued support in their clinical reviews. New tools on the horizon include:

- Development of tracking tools for risk indicators with subsequent trending and benchmarking. This will help us to pick up on developing issues and prevent incidents from happening.
- Increased standardization of record maintenance and documentation to allow easier transition during times of leadership change.
- Development of a facility evaluation tool for ADA risk factors.
- Completion of our facilities preparedness for the anticipated mandatory data reporting.

We are excited by our facilities accomplishments and eager to ensure their continued success. Special credit belongs to our tireless Directors, Carla Daley and Kim Reints. Their true devotion to excellence and quality patient care is obvious to our facility clinical leaders. The mentoring they provide to the clinical staff and their creative nursing leadership 'tricks' has created an environment where doing the right thing is not the exception, it's the rule.

Joyce Deno, COO Eastern Region
Regent Surgical Health
P. 708.492.0531
F. 708.731.5134