Leaders of healthcare organizations often must rely on monthly or quarterly meetings to assess their organization's readiness for the Joint Commission survey. As a result, key leaders typically cannot assess the current "health" of their organization in such key areas as clinical quality, staffing effectiveness, medical record quality, and environment of care. In addition, leaders are disconnected from the progress of focus reviews until these periodic meetings.

At Lady of the Sea Hospital, a 75-bed acute-care facility in Cut Off, Louisiana, information technology links the performance improvement, accreditation, and compliance activities of the quality, HIM (health information management), and other departments to senior leadership through real-time "dashboards." Instead of having to request or wait for meetings about, for example, the organization's performance on its chosen Core Measures clinical indicators, leaders at all levels have continuous, Web-based access to the latest performance metrics.

Because the information needed to power the "dashboard" required information from manual processes across the organization, a preliminary step in moving to real time was investing in the technology to automate processes like medical record and hazard surveillance reviews. Prior to automation, the nurses and other staff had to manually gather data, tally it, and produce the necessary reports — a labor-intensive and sometimes error-prone process. Now, once the data is entered in to the automated system, streams of data feed the enterprise's accreditation and compliance dashboard.

Moving to real-time management requires behavior changes for leaders and workers. Staff who had for years conducted reviews manually needed training on the automated processes and encouragement. In addition, the organization's leadership, newly empowered with real-time feedback, had to set new expectations for timeliness and quality of review activities. "We had given managers the tools to manage their individual... responsibilities faster and with fewer resources and now expected them to keep up," said Don Werner, director of performance improvement and compliance officer for Lady of the Sea.

In addition to saving resources, automating Lady of the Sea Hospital's accreditation and compliance activities and linking them to a real-time dashboard proved to be effective in helping the facility identify and fix performance and quality improvement activities well before JCAHO surveys. The organization can assessãat any given timeãhow it would perform on almost all aspects of the JCAHO survey. "We're working smarter, more efficiently, and can pinpoint exactly what our problems are and take immediate steps to bring about improvements," said Werner.

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