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Mock survey. Methodology for measuring compliance and facilitating change
K S Jackson1, P L Kuehn, K C Watkins
1Ohio State University Hospitals, Columbus.
The Journal of Nursing Administration
|January 1, 1994
Summary
Nurse executives must ensure healthcare organizations meet changing compliance standards. A proactive approach using the Joint Commission
Area of Science:
- Healthcare Management
- Nursing Administration
- Quality Improvement
Background:
- Nurse executives are responsible for maintaining compliance with external healthcare standards.
- Evolving standards necessitate ongoing organizational evaluation to ensure continued compliance.
Purpose of the Study:
- To describe how one healthcare organization utilized the Joint Commission on Accreditation of Healthcare Organizations' Agenda for Change to examine nursing practice.
- To detail the process of analyzing compliance, developing action plans, and conducting mock surveys.
Main Methods:
- Analysis of compliance with 1991 standards.
- Development of an action plan to address identified deficiencies.
- Creation and execution of a mock survey to evaluate the action plan's effectiveness.
Main Results:
- Increased staff comfort with the survey process.
- Improved understanding and use of monitoring tools and compliance data.
- Enhanced leadership development, team building, and networking among staff.
Conclusions:
- A structured approach to examining nursing practice against changing standards can improve compliance and staff confidence.
- Utilizing accreditation initiatives like the Joint Commission's Agenda for Change provides a framework for quality improvement in nursing.