Joint Commission Discovers 15 New Best Practices at Cleveland Clinic

After a five-day visit to Cleveland Clinic’s main campus and Northern Ohio family health centers, ambulatory care centers and outpatient locations, officials from the Joint Commission on Accreditation of Healthcare Organizations noted they were highly impressed.

In fact, they left the visit with 15 best practices in hand – all of which will be shared as resources for other Joint Commission-accredited hospitals and healthcare organizations.

“The best practices the Joint Commission identified are those that are considered ‘new’ to the surveyors, meaning they’ve never seen these exact practices, policies or protocols before,” says Meredith Foxx, Associate Chief Nursing Officer of Advanced Practice Nursing and Nursing Quality and Practice. “To have 15 best practices identified is a lot, even for a big organization like ours.”

The visit was Cleveland Clinic main campus’ triannual unannounced accreditation survey, which occurs for every Joint Commission-accredited organization at least every 36 months. The survey included 12 surveyors who could visit a total of 136 main campus sites.

In addition to the commendable number of identified best practices, surveyors found very few citations and most were corrected on the spot.

“The findings really speaks to how well we consistently conduct day-to-day operations,” Foxx adds. “Throughout the entire survey, the surveyors witnessed our health system goal to be the safest place for patients to receive care and for caregivers to work. They recognized that our caregivers want to learn and grow to provide the best care for our patients and that our culture supports and fosters that environment.”

Aaron Hamilton, MD, MBA, FACP, SFHM, Interim Chief Quality Officer for Cleveland Clinic health system, agrees.

“It was a phenomenal visit and an important reflecting moment for us to see and appreciate the exceptional teamwork we have in service of our patients. It validated that we are ‘patient-ready’ (instead of ‘survey-ready’) and every day, we are ready to care for patients in the highest-quality way,” he says. “At the close of our survey, the surveyors commented that throughout the week we fostered an awesome learning experience for them and they left feeling inspired. That statement is an incredible testament to the amazing work we are doing. If we can create that feeling for our surveyors, imagine how our patients feel when they leave the hospital.”

Stand-out successes

From systemwide work on opioids and sepsis to the use of visual management process confirmation boards and more, Joint Commission surveyors noted several instances in which Cleveland Clinic surpassed expectations.

The 15 best practices that made a lasting impression on the Joint Commission surveyors included:

  1. Daily Tiered Huddles
  2. Pharmacy Robots
  3. Mobile CT (Computed Tomography) Scanning
  4. Sibling Court/Daycare for Siblings of Cancer Patients
  5. 4th Angel Mentoring Program for Cancer Patients
  6. The Blessing of Donated Bone Marrow Cells Prior to Transplant
  7. Disposable MRI (Magnetic Resonance Imaging) Compatible Laryngoscopes
  8. Lead Apron Monitoring Program for Radiation Monitoring
  9. SHIELD Healthcare Safety Conference
  10. The Pause Moment of Silence at a Patient’s Passing
  11. Nurse-led Interdisciplinary Rounds for Complex Care Environments
  12. Red Inpatient “Do Not Disturb” Lights for Reducing Interruptions During Care
  13. Provider Rounding Tool
  14. OPPE (Ongoing Professional Practice Evaluation), FPPE (Focused Professional Practice Evaluation), and Peer Review Processes
  15. Rapid RCA (Root Cause Analysis) Process

“What’s especially impressive about these 15 highlighted practices is that many are utilized across our health system – not just at main campus. Additionally, they represent several departments, institutes and caregiver groups,” says Dr. Hamilton. “For example, daily tiered huddles are an executive leadership initiative, the blessing of bone marrow cells was a collaboration between the Center for Spiritual Care and oncology caregivers and the SHIELD Conference resulted due to a partnership with the Nursing Institute and Protective Services.”

Nursing-driven best practices

Foxx notes that four of the Joint Commission’s 15 identified best practices originated from Cleveland Clinic’s Stanley Shalom Zielony Institute for Nursing Excellence.

  • SHIELD Conference.
    The SHIELD Conference is a biannual healthcare safety event designed to educate frontline caregivers and support staff on social factors that impact safety in healthcare. The April 2018 event featured keynote speakers, educational lectures and poster presentations that addressed violence in healthcare, disaster preparation, drug epidemics and general security. It also recognized stress points that clinicians, patients and visitors face every day – providing attendees with practical tactics and skills to manage these situations.

The idea to host a caregiver safety conference came after discussions among Cleveland Clinic’s executive nursing leadership team about the growing concerns of violence and burnout in the workplace. The team approached Cleveland Clinic’s Protective Services about developing an education event, and SHIELD was born.

  • The Pause.
    “The Pause” is a 15- to 30-second period of silence held by caregivers at the bedside at the time of a patient’s death. The moment of silence is intended to honor the life of the patient who has passed and recognize the work of the caregiver team, while providing closure for caregivers and preparing them to care for future patients. It is initiated by a physician or nurse and participation is voluntary. Caregivers can provide anyone present, including family members, with “The Pause” card, which is available in English, Spanish, Arabic, Russian, Mandarin and Cantonese.

The names of patients who pass away each day are also read every morning at Cleveland Clinic’s Tier 6 Daily Tiered Huddle (CEO and Operations Council). Cleveland Clinic’s Center for End of Life Care, along with the Nursing Institute, adopted the original idea from a University of Virginia Medical Center emergency department and palliative care liaison nurse.

  • Interdisciplinary Rounds.
    Nurse-led interdisciplinary rounds occur in Cleveland Clinic’s complex patient population nursing units, such as intensive care, neonatal intensive care, heart failure and so on. The purpose of the rounds is for nursing caregivers to bring together the entire care team to discuss patient-specific information, such as medical issues and care that’s not progressing. Through the rounds, nurses are able to address unresolved issues and get immediate answers from other care team members, to more quickly advance care and save valuable time. Among other objectives, the daily nurse-led interdisciplinary rounds help achieve quality outcomes, enhance patient care and satisfaction, improve the care team’s understanding of patient-specific goals, create faster problem resolution, improve compliance with evidence-based practice guidelines and reduce length of stay. Rounds may include team members such as charge and bedside nurses, intensivists, residents, dietitians, case managers, pharmacists, trauma coordinators, pastoral care representatives and attending physicians.
  • “Do Not Disturb” Lights.
    Implemented on various inpatient nursing units, such as the pediatric ICU and medical-surgical units, “Do Not Disturb” lights, which are red in color, are located outside the doors to patient rooms. When lit, the lights indicate that a nursing caregiver is in the room with a patient and should not be disturbed.The lights help to eliminate potential distractions for nursing caregivers and serve as a visual tool for reducing interruptions, which can increase chances for error and leave nurses feeling pulled in multiple directions. They are most commonly used when nurses are administering medications and have helped heighten awareness and empower nurses to safely administer medications without unnecessary interruptions. They have also helped increase nurse satisfaction.

Nurses offer a lay of the land

According to Foxx, Cleveland Clinic’s nurses were the primary escorts and communicators for Joint Commission surveyors throughout the recent site visit.

“Nurses are great in this role because they can comfortably and confidently speak to our level of engagement, performance improvement, quality improvement and continuous improvement as they are leading and driving a lot of these areas,” Foxx adds. “During the survey, you could sense how proud Cleveland Clinic’s nurses were of the patient care they provide.”