ACHIEVING CONTINUOUS EXCELLENCE: HOW ONE OUTPATIENT ONCOLOGY CENTER MAINTAINS ACCREDITATION READINESS

2.50
Hdl Handle:
http://hdl.handle.net/10755/164967
Category:
Abstract
Type:
Presentation
Title:
ACHIEVING CONTINUOUS EXCELLENCE: HOW ONE OUTPATIENT ONCOLOGY CENTER MAINTAINS ACCREDITATION READINESS
Author(s):
Fujimoto, Irene; Hart-Inkster, Beverly
Author Details:
Irene Fujimoto, MSN/MHA, OCN, Clinical Reimbursement Specialist, Alta Bates Summit Comprehensive Cancer Center, Berkeley, California, USA, email: iafuj@mac.com; Beverly Hart-Inkster, BSN, OCN
Abstract:
Administration/Leadership Development: All healthcare facilities that strive for the Joint Commission (TJC) accreditation face the inevitable question of how to maintain a level of standards compliance on a daily basis as opposed to ôgearing upö for the triennial survey. Since 2007, the Joint Commission no longer provides advance notification of survey dates. In any improvement change process such as being at a continuous state of compliance, stakeholders must insure that the changes integrate into the culture of the organization. The alternative is a return to the unacceptable practices that were present before the improvements and a potential for losing accreditation. In order to maintain a state of continuous standards compliance, the Alta Bates Summit Comprehensive Cancer Center (ABSCCC) organized an interdisciplinary team of staff representatives from each area of this outpatient oncology department. Under the acronym, ACE Team (Achieving Continuous Excellence) borrowed from a similar managerial committee in the host hospital, the staff, not just leadership, maintains scrutiny for any deficiencies. By tapping into the commitment of frontline staff, all employees of the Cancer Center became accountable for survey readiness. Each month, ACE Team members conduct environment of care surveys in their areas and question peers on standards topics such as National Patient Safety Goals, infection control and HIPAA. Clinical staffs also review a sampling of medical records to ensure completeness of documentation. When Team members identify discrepancies, corrective action occurs immediately. Monthly surveys demonstrate a high level of standards compliance in the 85 to 95% range. Monthly Team meetings provide a forum for voicing staff concerns and areas that need addressing by leadership and administration. Accreditation by TJC affects healthcare organizationsÆ ability to receive Medicare reimbursement and thus, has crucial implications for the organizations' ability to provide services. Shifting away from a mentality in which the impending accreditation survey is a crisis, and involving frontline staff in the process of maintaining readiness becomes the logical and healthier way to practice healthcare. At ABSCCC, practicing according to TJC standards on a continuous basis eliminates the crisis mentality and creates a safe environment to provide oncology care for both patients and clinicians.
Repository Posting Date:
27-Oct-2011
Date of Publication:
27-Oct-2011
Conference Date:
2009
Conference Name:
34th Annual Oncology Nursing Society Congress
Conference Host:
Oncology Nursing Society
Conference Location:
San Antonio, Texas, USA
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.

Full metadata record

DC FieldValue Language
dc.type.categoryAbstracten_US
dc.typePresentationen_GB
dc.titleACHIEVING CONTINUOUS EXCELLENCE: HOW ONE OUTPATIENT ONCOLOGY CENTER MAINTAINS ACCREDITATION READINESSen_GB
dc.contributor.authorFujimoto, Ireneen_US
dc.contributor.authorHart-Inkster, Beverlyen_US
dc.author.detailsIrene Fujimoto, MSN/MHA, OCN, Clinical Reimbursement Specialist, Alta Bates Summit Comprehensive Cancer Center, Berkeley, California, USA, email: iafuj@mac.com; Beverly Hart-Inkster, BSN, OCNen_US
dc.identifier.urihttp://hdl.handle.net/10755/164967-
dc.description.abstractAdministration/Leadership Development: All healthcare facilities that strive for the Joint Commission (TJC) accreditation face the inevitable question of how to maintain a level of standards compliance on a daily basis as opposed to ôgearing upö for the triennial survey. Since 2007, the Joint Commission no longer provides advance notification of survey dates. In any improvement change process such as being at a continuous state of compliance, stakeholders must insure that the changes integrate into the culture of the organization. The alternative is a return to the unacceptable practices that were present before the improvements and a potential for losing accreditation. In order to maintain a state of continuous standards compliance, the Alta Bates Summit Comprehensive Cancer Center (ABSCCC) organized an interdisciplinary team of staff representatives from each area of this outpatient oncology department. Under the acronym, ACE Team (Achieving Continuous Excellence) borrowed from a similar managerial committee in the host hospital, the staff, not just leadership, maintains scrutiny for any deficiencies. By tapping into the commitment of frontline staff, all employees of the Cancer Center became accountable for survey readiness. Each month, ACE Team members conduct environment of care surveys in their areas and question peers on standards topics such as National Patient Safety Goals, infection control and HIPAA. Clinical staffs also review a sampling of medical records to ensure completeness of documentation. When Team members identify discrepancies, corrective action occurs immediately. Monthly surveys demonstrate a high level of standards compliance in the 85 to 95% range. Monthly Team meetings provide a forum for voicing staff concerns and areas that need addressing by leadership and administration. Accreditation by TJC affects healthcare organizationsÆ ability to receive Medicare reimbursement and thus, has crucial implications for the organizations' ability to provide services. Shifting away from a mentality in which the impending accreditation survey is a crisis, and involving frontline staff in the process of maintaining readiness becomes the logical and healthier way to practice healthcare. At ABSCCC, practicing according to TJC standards on a continuous basis eliminates the crisis mentality and creates a safe environment to provide oncology care for both patients and clinicians.en_GB
dc.date.available2011-10-27T12:10:11Z-
dc.date.issued2011-10-27en_GB
dc.date.accessioned2011-10-27T12:10:11Z-
dc.conference.date2009en_US
dc.conference.name34th Annual Oncology Nursing Society Congressen_US
dc.conference.hostOncology Nursing Societyen_US
dc.conference.locationSan Antonio, Texas, USAen_US
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission. Alternatively, please contact the conference host, journal, or publisher (according to the circumstance) for further details regarding this item. If a citation is listed in this record, the item has been published and is available via open-access avenues or a journal/database subscription. Contact your library for assistance in obtaining the as-published article.-
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