OR Manager March 2022 - 11

Leadership Series
Q: What other qualities must
a leader exhibit? And how do
leaders learn these qualities?
I have always learned something valuable
from leadership training. They
teach you concepts, scenarios, and simulations.
But nothing prepares you more
than learning from first-hand experience.
You have to stay up-to-date with best
practices, standards of care, and performance
indicators. You must pay attention,
track, and trend your department's
performance compared with
benchmarks in quality measures. There
are also revenue and returns to track.
In terms of finance, you are constantly
monitoring productivity and efficiency.
Staying informed will enable you to
make better decisions and plan strategically
for the future.
Q: You just completed a Joint
Commission compliance audit
for your facility. What did that
entail?
The Joint Commission is an independent,
nonprofit organization that certifies
or accredits healthcare organizations.
They perform audits and on-site
surveys every three years to ensure
healthcare organizations adhere to
regulations and maintain standards of
care. The on-site survey involves multiple
things. To name a few, it requires
inspection of:
* environments of care: inspecting the
physical facility to ensure the structure
is within code temperature, and
humidity levels in patient care areas
are within range
* life safety: that includes fire safety
and chemical spills
* infection prevention
* medical records: conducting patient
tracer methodology by reviewing patient
charts from admission to discharge,
to ensure accurate and complete
documentation of physician orders,
medication reconciliation, and
patient consent
* universal protocol (perioperative serwww.ormanager.com
vices):
this is checking for patient
consents, health assessments, upto-date
history and physical, preoperative
briefing, and time-out before
surgical incision
* practices, clinical or otherwise:
checking that these are consistent
with the organization's policies.
Q: How do you prepare for a
survey?
It takes a village to prepare for a survey.
First, you have to have a good grasp of
The Joint Commission's current rules
and regulations. You use this as a reference
during the preparation.
Hopefully, your facility has a robust
quality department because you will rely
heavily upon them throughout the preparation.
They can provide you with findings
identified from previous surveys,
observation checklists, and auditing
tools specific to your department. The
quality department can also assist with
conducting " roundings " or observations.
As a leader, you should conduct daily
observations or " roundings " in your department
before the survey. You try to
identify deficiencies and come up with
plans for correction. The observations
should be done regularly, scheduled
or unannounced, to identify new findings
and prevent recurrence of previous
findings. When the survey is imminent,
senior leadership and the quality department
will conduct a " mock survey, " as
a sort of dress rehearsal to the actual
survey.
A leader should keep the team wellinformed
during the preparation. Inform
them of the findings, how the department
is progressing, plans of correction,
and provide coaching and counseling for
recurrent findings. Encourage the team
to get involved and provide solutions,
which is an excellent way to hardwire
staff members prior to the survey.
You should always strive to have zero
findings. If you do have a finding, you
need to formulate and submit a plan for
correction. Depending on the finding,
this involves:
1. Review policies to ensure that current
practice is consistent with
the policies and protocols. If the
guidelines are inconsistent with
current regulations, policies will
have to be revised.
2. Educate staff, that is, inform staff
of the finding, as well as plan of
correction and training.
3. Audits or observations are performed
to ensure team members
adhere to the corrections. This involves:
a) compliance measures
(95% compliance or above), b) for
a particular duration of time (usually
four months), c) and frequency
of observation (daily, weekly, random).
If the department is unable
to maintain compliance above the
threshold, the duration of the audit
will extend (an additional month)
until compliance above the threshold
is attained.
Q: How did you know it was time
to move up the career ladder?
I never really aspired to be in a management
position. I was happy working in
the OR scrubbing or circulating surgical
cases. I practiced what I learned within
my clinical scope, maintained professional
conduct, and worked as part of
the team. As time went by, the department
leaders encouraged me to take
on a leadership role and gave me more
responsibilities. I was a resource nurse
for neuro, spine, and ENT cases at first.
Then I was offered my first management
position as clinical coordinator/supervisor.
Somewhere along the way, after
having my first management experience,
I felt like I needed something more.
I became more interested and
learned as much as possible to be a
leader. I started attending leadership
training and seminars. But as I mentioned
earlier, nothing teaches you as
much as first-hand experience. I became
more focused on the nuances of
Continued on page 12
OR Manager | March 2022 11
http://www.ormanager.com
OR Manager March 2022

Table of Contents for the Digital Edition of OR Manager March 2022
