ISSUE: Multiple compliance rounds by infection control, safety, and regulatory compliance departments were being performed with an overlap of efforts and occasional conflicting information being presented to managers.

PROJECT: In 2002 a proposal was made to combine infection control, safety, and Joint Commission of Healthcare Organization Accreditation (JCAHO) compliance rounds into a single document to be used in a multifacility healthcare organization. A group was formed, composed of the above departments, along with members of engineering, nursing administration, and education. Meetings were held to discuss and review each department's current forms and requirements. During this stage, any information that appeared to be in conflict was researched and an appropriate response agreed upon. Education among the group occurred so all members were equally familiar with particular items on the form. This form evolved into what is referred to as the scan tool. Two-member teams were formed and assigned to various areas of our healthcare organization. The teams use the scan tool to review an area, and results are given to the department manager with a deadline to respond to “opportunities to improve.”

RESULTS: This process provides for a consistent approach to compliance rounds. It also gives the department managers a single form that allows them to see, at a glance, where they have any regulatory deficiencies. The results are shared with department directors and upper management, which has had a twofold benefit. First, on the department level, managers feel they have support to make necessary changes based on deficiencies identified. Second, they know the report is reviewed and that continued deficiencies will be questioned. Further, our acute care facility received magnet recognition status in January 2004 and nursing administration has requested magnet representatives be trained as “scanners” to allow for a more proactive approach on nursing units to keeping their areas in compliance.

LESSONS LEARNED: What was once a disjointed effort among several departments has evolved into an effective monitoring system. It continues to be a fluid process, with revisions improving ease of use for both scanners and managers. Most important, administration regards this process as a critical activity to maintaining an atmosphere of continuous readiness for unannounced regulatory surveys.