They're coming...

is what I heard early Tuesday morning as I was checking expiration dates on our unopened medications in our med 2 room at the hospital. We were anticipating their arrival. We were all dressed up, but their coming was unannounced, so to hear the actual words, "They're coming," hit like a knife. I am speaking about Joint Commission...for our big hospital audit! I and my leadership team had been working countless hours and were exhausted; infact, we had just pulled major overtime that weekend, so we were hoping for an arrival that week. Like I had just mentioned previously, Joint Commission shows up unannounced. We give them a date that we are ready and they can show up on that date or any time within 3 months. We had given them the date the week prior, but the CEO and Corporate just had a feeling they would show up on 3/27 and man they were right. Okay, back to my story...I had heard the news! I walked into report room to let my staff know who were coming on shift. Man, my staff are amazing! They were ready; infact a few of them jumped right up to help me clear things off my floor of my office (nothing can be stored on the floor per Joint Commission.) At this time, some nerves hit me and my charge nurse walks by me as he is hauling one of my boxes out of my office and he tells me, "We got this!" All of a sudden, the nerves leave! He was definitely right! We did have this! We have been preparing since December and working over time since the beginning of February. We did have this :). Me and the Clinical Director were assigned the Audit leads which meant we were with the auditors the whole time...come to think of it we were suppose to come up with team names because she always had one auditor while I had the other, but being too busy we never did, lol! There were 3 auditors that showed up that morning, a nurse, a Dr, and an engineer. The nurse was the lead auditor. Lucky me, she was tough, but I loved it! She challenged every question everyone had. You answered a question and she challenged it. I loved it becaused it made you think and she was great at educating! The first day we did an opening session where the auditors got to know me and my fellow leadership team. Then I went to a rehab group with the nurse auditor. She loved it and so did I. It was great to have her sit in on one of our groups because we run great groups at our hospital and it was on spirituality which is a hard group to conduct, but she gave our therapist kudos on the great job she did! Then we did individual tracers. That is where the auditors pull staff in and ask them questions about the patients etc. They pulled my charge nurse in and he did awesome!! Unfortunately, I was only able to sit in on him with one and he could probably kill me for not being able to sit with him on the others, but he did fantastic!! I am so lucky to have him as my day shift charge nurse!! Then the first day was over!! I was hoping to get off work at a decent time, but I had to check my med room to make sure it was continuing to be up to par and read over some more policies, so my sweet, sweet husband went shopping for me!! I wanted some nice clothes to wear for the next 2 days and he did a fabulous job picking them out. Everyone at work said my husband has great taste...he has been trained very well :)

Jessica T. (my infection control nurse..on the left) Jesse (day shift charge nurse...in the middle) and me (on the right) at the end of the first day making sure our med room shines for day 2!!!

Me in my business suit ready for day 2!! Spencer DOES have great taste!


The 2nd day was HUGE for nursing! I had 2 major sessions...medication management and infection control! I also had 2 major tracers...medication room and medication pass. Me and the leadership team met with all 3 of the auditors in the morning for a daily debriefing to find out how things went the day before...so far so good...AWESOME!!! Then the nurse auditor wants to see our med room. At this point, I feel my heart become a little tachycardic (fast!) We had an audit in 2010 and the auditor found a lot of things wrong in the med room. I could go in to details, but it could bore some people. The audit prior to that also found things wrong in the med room and due to all that, the DON was let go and I was asked to be the DON, so yes a fast heart beat is very understandable. The nurse auditor walks into the med room and starts asking my nurses questions and they do a GREAT job. Then she starts asking to see stuff in the med room and looking around. I am so PROUD to say she did not and I repeat she did NOT find a single thing wrong with that med room!!! Then she watches my nurse do a med pass. Now, the nurse auditor finds what happens next quite comical, but at the time, I could have cried or freaked out...My nurse has the medication in hand with me and the auditor following...we walk down to the patient's room and he is not there. We walk into the group room, he is not there. We walk into the day room, he is not there. At this time, panic comes across mine and my nurse's face. This patient is on a locked unit and the only way he cannot be on the unit is if he went AWOL. We got up to my tech who is checking on the patient every 15 minutes and in the calmest way possible, ask where is the location of the patient...the tech says in his bed. We say, "No, he is not." My nurse, being the great nurse that she is, immediately found this patient in another patients bed!! Now, this all took only about 2 minutes, but seemed like forever AND the med pass went beautifully! The nurse auditor enjoyed the show and when we went back to Administration she just had to share the story. She's been there. She's been a psych nurse and a DON. She loved mentioning our panic stricken faces!! Then I had a med management tracer with the Dr auditor. Everyone said this session was the HOT TICKET because this is probably what we were worried about most! We changed our whole med system around because we are growing and we are in the middle process of bringing in an inhouse pharmacy, so I had to speak to what we do now and we had our wonderful pharmacy consultant to help speak to our inhouse pharmacy coming in a couple weeks. It went FABULOUS! My boss even sat in on this one because seriously, it was the HOT TICKET!! Then right after that I had an infection control session with the nurse auditor. She interviewed my infection control nurse and that went FABULOUS as well. My infection control nurse did such a great job and at the end the nurse auditor asked her why she thinks I chose her to be the infection control nurse, as she answered, we both got teary eyed. Her and I have worked very closely preparing for this audit and she has done such a great job strengthening our infection control program. I am so proud of her. After the audit, I joked with her because she worked out with me with Chalene Johnson the day after Christmas and we talked about how we want to help our hospital pass the audit and then we both want to become fitness instructors so I mentioned to her after the audit that it's time to move onto our next goal, haha!!


The 3rd and final day!! Once again my leadership team and I met with the auditor and talked about the day before. The nurse auditor spoke...well laughed about the med pass experience and said that went great as well as the med room!! Then I had 2 more sessions with them...Leadership and Competence. Leadership was with all of us department heads and they asked us all how we are going to continue to manage our departments as our hospital grows. Then at the very end they asked us to go around the table and tell us one thing we have learned through this process. I cannot remember the exact words that I said, but I was definitely moved to say what I said. It went something like this...I have seen who can rise to the occasion. It has been a tough road, but through this, I have seen who genuinely cares about this hospital and the patients. I also mentioned that we have implemented a lot of new forms (that was also a little joke the auditors had because they've been in our shoes and they know we have been so busy and they see all the new and different forms we have started) and I have seen the patience the staff have to learn and implement them while still taking great care of the patients. After this, I had the competence session. This was where the Nurse auditor met with me, the clinical director, CEO, and HR director and asked us questions about how we train our staff and know they are competent. It went wonderful! Then we let the auditors review charts and do paperwork for a couple hours and they said we would find out the "news" at 1:30pm. I went back to my office to catch up on work for the week. I then received a tender mercy. This tender mercy is so dear and sweet to my heart. I immediately called Spencer and text my mom. There were times preparing for this audit that I struggled. It was HARD. I am sure if you ask anyone in administration they will tell you this is the hardest thing they have every experienced in their career. I am a new nurse and it was tough. BUT, this tender mercy testified to me that I am on the RIGHT path and I am doing what is RIGHT! When I told Spencer and my mom they were amazed as well. The Lord is definitely here for us if we let Him in and He definitely answers prayers!!

At 1:30pm, there was a page overhead for the leadership team to head to the conference room. I was so excited walking down the hall! I knew in my heart what the news was going to be! Well, we all sat together with the audtiors and we heard the news~ You are accredited! Hospital accredited! Before, we were behavioral standards, now we are hospital standards which means we have the same accredidation as major hospitals such as IMC. We are so thrilled. Hard work definitely pays off. I am so proud of my staff and the leadership team! They are amazing!!