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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Volume 1, Issue 1

2009 National Patient Safety Goals - Complete Quality

Susan Wisniewski, MPA, CPHQ
Manager, Accreditation and Regulatory Compliance


Children's Hospital Central California Nurses have noticed the icon - Complete Quality - on the Hospital’s intranet site. Complete Quality is a philosophy which represents the Hospital’s shift away from a culture of preparing for the next survey to a culture of preparing for the care of our next patient. We are developing a culture of safety and quality while providing extraordinary care for our patients. 

Nursing Excellence IconBeing prepared for a survey is important and is a shared accountability. Our success depends on each and every employee. It is our responsibility to be knowledgeable about standards, policies and processes throughout the Hospital.  We must be able to articulate our role and its importance in patient care.   

The Hospital evaluates findings from patient tracers, organizational assessments and daily monitoring of our regulatory and accreditation environment to ensure compliance.

Tracer Program

The patient tracer methodology was adopted by The Joint Commission in 2005 and is used as a mechanism to survey hospitals. In a patient tracer, a patient is selected and the care of that person is traced through every area of the hospital that they visit. Children’s Hospital elected to replace mock surveys with this method to evaluate compliance with laws, regulations, standards as well as our own policies and procedures, to determine if we have appropriately applied the standards to our practice.

Patient tracers were initiated at Children’s Hospital in the fall of 2006. In January 2007, 26 tracers were completed. The program continues to grow; in fiscal year (FY) 08 we completed 58 tracers. Patient tracers are conducted by a team of directors from both clinical and non-clinical areas, as well as managers and supervisors appointed by each director. Tracer team members receive an orientation to the process and observe several tracers prior to actively participating on a team. 

There are multiple benefits from patient tracers. Issues are identified and leaders are empowered to make needed improvements in their unit. Staff participating at the unit level learns to articulate their role and responsibility and recognize the importance of their involvement in the coordination and delivery of care. Everybody learns that keeping children safe is the same as preparing for a survey.

To close the communication loop, a unit based report is sent to the director of each unit participating in the tracer. The director has the opportunity to initiate changes in processes or provide additional education to staff. All findings are maintained in a database which is reported to the Executive Council and the Directors Forum, becoming the basis and support for new performance improvement projects. This collaborative effort promotes success at every level.

Organizational Assessments

An assessment of Title XXII and Centers for Medicaid and Medicare Services (CMS) is conducted bi-annually to monitor and evaluate changes in the regulatory and accreditation environment as well as the Hospital’s compliance to laws and regulations. Additionally, an annual comprehensive assessment of our compliance to The Joint Commission’s standards is conducted in July. The Hospital identifies opportunities that can be incorporated into the organization’s performance improvement plan. The Tracer Program helps to monitor changes as they occur. Compliance with laws, regulations and standards are a good indicator that patients are receiving safe care. 

Resources for Children's Employees

  • Complete Quality Webpage: Complete Quality resources are available on Children’s intranet by clicking on the Complete Quality intranet page. You will find the tools you need to assess procedures and practices as well as evaluate the quality and safety of patient care. You will find the latest edition of The Joint Commission manual, recent publications regarding standards and regulations, survey preparation materials and tracer program information.
  • Consultation: Staff is available to assist you with research on Title XXII, CMS and The Joint Commission laws, regulations and standards. There are opportunities for you to Raise your CQIQ with educational programs related to survey preparation. Consultation is available for the development and/or revision of policies.
  • Employee Guidebooks: Employee Guidebooks, revised by the Accreditation and Regulatory Compliance Department, will be distributed early this year. Leaders also received a Leadership Handbook to assist in learning important and applicable standards to educate staff in preparation for a survey.

The primary focus of Complete Quality and continuous regulatory readiness is to enhance our culture of safety and quality. Our goal is to enhance the quality and safety of patient care. We all win with complete quality. Everyday, you have the opportunity to keep Children’s Hospital ready and in tip-top shape for an unannounced survey. Remember: providing quality care + keeping children safe = survey readiness.

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