Episode 18 - Is Water Against The Rules? Diving Into Compliance
May 15, 2026
About This Episode
Many nurses have heard that keeping a water bottle at the nurses station violates The Joint Commission standards. But is that true?
In this episode of Better RN, hosts Alyssa Saklak, BSN, RN, CMSRN, and Laurin Henderson, MSN, RN, CMSRN, talk with Northwestern Medicine Accreditation, Clinical Compliance and Policy managers Rene Catalano, MS, RN, and Besa Tole to separate fact from fiction. They explain where the “no drinks at the nurses station” myth likely began, who sets workplace safety standards and how regulatory surveys help nurses provide safer care.
“We think the myth may have started because of a simple misunderstanding. If one regulatory body prohibits drinks from certain work areas, people may assume all regulatory bodies prohibit them everywhere. That’s not the case.
Besa Tole
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Medicine Central DuPage Hospital
“The reason these regulations are in place is because things have happened. Harm has happened. From the trends our regulators see across the nation and across the globe, standards and regulations are developed based on events that have occurred in the field. That is why we have to protect ourselves and our patients.”
Rene Catalano, MS, RN
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Memorial Hospital
Show Notes
Episode Guests
Besa Tole
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Medicine Central DuPage Hospital
Rene Catalano, MS, RN
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Memorial Hospital
Many nurses have heard that keeping a water bottle at the nurses station violates The Joint Commission standards. But is that true?
In this episode of Better RN, hosts Alyssa Saklak, BSN, RN, CMSRN, and Laurin Henderson, MSN, RN, CMSRN, talk with Northwestern Medicine Accreditation, Clinical Compliance and Policy managers Rene Catalano, MS, RN, and Besa Tole to separate fact from fiction. They explain where the “no drinks at the nurses station” myth likely began, who sets workplace safety standards and how regulatory surveys help nurses provide safer care.
“We think the myth may have started because of a simple misunderstanding. If one regulatory body prohibits drinks from certain work areas, people may assume all regulatory bodies prohibit them everywhere. That’s not the case.
Besa Tole
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Medicine Central DuPage Hospital
“The reason these regulations are in place is because things have happened. Harm has happened. From the trends our regulators see across the nation and across the globe, standards and regulations are developed based on events that have occurred in the field. That is why we have to protect ourselves and our patients.”
Rene Catalano, MS, RN
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Memorial Hospital
Show Notes
- Tole and Catalano explain that the belief that water at the nurses station is against the rules likely comes from a misunderstanding of Occupational Safety and Health Administration (OSHA) workplace safety requirements, rather than a standard of The Joint Commission. They also discuss how hospitals can support safe hydration through designated hydration stations.
- They discuss how The Joint Commission, Centers for Medicare & Medicaid Services, OSHA and state regulators work together to establish healthcare standards. They explain why hospital policies may be more stringent than national regulations and how those policies are designed to protect patients and healthcare workers.
- Tole and Catalano share a behind-the-scenes look at their work translating regulations into everyday practice. They explain how compliance teams collaborate across Northwestern Medicine, review changing regulations, standardize policies and rely on feedback from frontline staff to make sure policies are practical and compliant.
- Accreditation can be stressful for nurses, but Tole and Catalano say these visits should be viewed as opportunities for improvement, not reasons for fear or anxiety. They explain how surveyors identify potential risks, encourage continuous quality improvement and help hospitals strengthen systems before problems affect patient care.
- They remind nurses to approach regulatory surveys with confidence and honesty, and to use available resources when they do not know an answer. They say surveyors are partners in the shared goal of safer, higher-quality patient care.
Episode Guests
Besa Tole
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Medicine Central DuPage Hospital
Rene Catalano, MS, RN
Manager, Accreditation, Clinical Compliance and Policy, Northwestern Memorial Hospital
transcript
[00:00:01] Alyssa Saklak: I'm Alyssa Saklak.
[00:00:02] Laurin Henderson: And I'm Laurin Henderson.
[00:00:03] Alyssa Saklak: On Better RN, we get real about nursing,
[00:00:06] Laurin: The good and the gritty.
[00:00:08] Alyssa Saklak: We talk to real healthcare experts.
[00:00:10] Laurin: With the goal of becoming better
[00:00:12] Alyssa Saklak: For our patients, our colleagues,
[00:00:14] Laurin: Our family, our friends,
[00:00:16] Alyssa Saklak: Our partners, and ourselves.
[00:00:20] Laurin Henderson: Hi, Alyssa.
[00:00:21] Alyssa Saklak: Hi, Laurin.
[00:00:22] Laurin Henderson: I'm excited for today's episode; we're talking to two Northwestern Medicine employees today about all things regulatory.
[00:00:30] Alyssa Saklak: I feel like my heart pitter-patters a little bit quicker whenever I feel like I am being put on the spot in front of an accreditor, and it's scary.
[00:00:37] Laurin Henderson: I remember my first time as a manager when we had surveyors in-house, and you think that it's going to be me that shuts this place down for something silly. But that's actually not the case. And Rene Catalano and Besa Tole are going to talk to us today about how actually a lot of these regulatory bodies want to work with us. They want to make things better and they want to find our weak spots so that we can improve and do better for our patients and our staff.
[00:01:01] Alyssa Saklak: And I think that Northwestern Medicine has a lot in place to make sure that we're successful to break down some of the fear, myths, and stigma around what it means to be a bedside healthcare provider and have someone come in and question your policies, procedures, and standards of care.
[00:01:18] Laurin Henderson: They talk about this specific type of adrenaline rush that they get from doing this certain type of work, which, to each their own. It's not my kind of adrenaline, but I'm very glad that we have people that love this work.
[00:01:30] Alyssa Saklak: We are so lucky, and Northwestern Medicine is a large healthcare system and there's different sites that have different complex environments. And so there's a lot of care that we standardize on that we do across the system, and each site has its unique challenges. But I think it's fascinating the work that they do and the tremendous amount of governing bodies that are the checks and balances of healthcare and hospital systems. And how do we fit into the mix and how do we advocate for the things that we need in our care environments?
[00:01:59] Laurin Henderson: And what's real and what's not.
[00:02:00] Alyssa Saklak: And the biggest myth of all: Is water really against the rules in the nurses station?
[00:02:06] Laurin Henderson: For years a lot of people felt like drinking water at the nurses station was somehow against the rules and having a water bottle at the nurses station was going to shut the place down and get us cited by The Joint Commission, which is the independent organization that accredits and certifies thousands of hospitals across the country, and the one that we, I think, focus on the most today in our conversation. However, they have publicly addressed that issue, saying that no, water at the nurses station is not their rule; it's actually a myth. So where did this idea come from? Who decides whether you can have water at your workstation? And Rene and Besa help us suss this out.
[00:02:39] Rene Catalano: Thank you for having us.
[00:02:41] Laurin Henderson: Well, thank you both for coming on the podcast. Tell us a little bit about yourselves, who you are, and your role here at Northwestern Medicine.
[00:02:48] Besa Tole: My name is Besa Tole. I am the accreditation, clinical compliance, and policy management manager at Northwestern Medicine's Central DuPage Hospital. I have a lab background, actually, and I've been here almost 14 years —14 years in September.
[00:03:02] Rene Catalano: And I'm Rene Catalano. I hold the same title at Northwestern Memorial Hospital downtown. And my background is as a critical care nurse for 25 years here downtown, and I was also an education coordinator for 19 of those years. I've been at Northwestern Medicine going into my 39th year in August.
[00:03:22] Laurin Henderson: Well, we're really happy that you both agreed to come talk with us today. When we're talking about The Joint Commission and regulatory bodies, obviously Alyssa and I are nurses by background, so those are like black clouds to us. We don't love to hear that those people are coming. What got you interested in going into this line of work within your nursing and your lab background? How did you get to this spot?
[00:03:48] Rene Catalano: Well, I was an education coordinator and a critical care nurse for many years and just wore different hats in that role — just even as a resource coordinator at one point as a clinical practice consultant. And I pretty much had my dream job. But I wanted to get more in touch with the "why" behind all of the hospital regulations, and that drove me to seek a position within the quality department and accreditation as part of that. And it's been a lot of years of learning, but understanding hospital policy and understanding regulators that come in and evaluate hospitals and the reasons why we have these regulations has really fostered a new appreciation for me as a nurse.
[00:04:32] Laurin Henderson: Besa, would you say you've had a similar path?
[00:04:34] Besa Tole: Well, I was the lab educator and the point-of-care coordinator, and that actually fell under quality in the lab. And it was kind of an adrenaline rush when we had CAP inspections, and I liked it. So it was interesting to kind of get the hospital side of regulatory and quality. So it was kind of, in a way for me, a fun path to go because I am not a nurse, so it's a huge learning curve. But it's been fun.
[00:04:58] Alyssa Saklak: I love that you described it as like an adrenaline rush, because I feel like that's the perfect way to describe it. And I very vividly remember some of the first — I would call it our "houseguest" — whether it was an auditor of The Joint Commission or CMS. But when I walked in and Rene was sitting there and I was being pulled to, like, help with this, Rene, you had such a calm to you. And I internally was panicking, like, "Am I going to say the right thing?" "Did we do the right thing?" You are the stabilizer when we are being put to review these things. So, thank you for that.
[00:05:33] Besa Tole: Of course, a team. We're calm on the outside, but on the inside, we feel the same way.
[00:05:39] Laurin Henderson: I think that's the half of it, right? Just putting on a bold face. But when any regulatory body for any sort of survey comes in, I think nursing gets a little on edge because we know we're doing good work and we know we're doing the right thing. But there are these myths that have made it to the bedside somehow that The Joint Commission specifically is coming in and looking for water bottles. They want to see 'em at the nurses station and they want to cite us for it. Can you talk a little bit about the idea that is their "bread and butter"? They're just looking for the water bottles. Where did that idea come from and is it true? Is that a Joint Commission rule that you can't drink water at the nurses station?
[00:06:17] Besa Tole: So, we think the myth may have started because of a simple misunderstanding, right? So if one regulatory body prohibits drinks from certain work areas, then people just assume all regulatory bodies must prohibit them everywhere. So, really, that's not the case. There was most likely some type of OSHA citation at one point that there were drinks near some chemicals or potentially infectious material, or maybe somebody actually got, like, hurt from it — there was a true exposure. That kind of led people to this broad conclusion that drinks at a workstation are universally banned. So, it is a myth, and social media loves to play on that. So we've kind of seen that Nurse Blake comedy bit with The Joint Commission pointing at water. The nursing station is really funny, but it's really a misconception. So, they're trying to clear it up; it's not a true standard.
[00:07:03] Laurin Henderson: So they don't want nurses to be dehydrated is what you're saying. Perfect. OK. That, if anything from this episode.
[00:07:15] Besa Tole: Exactly.
[00:07:16] Laurin Henderson: Talk to us about hydration stations. What does that mean? What's the concept? Why do we --
[00:07:20] Besa Tole: Yeah. I mean, we want water, right? Like, everybody needs to be hydrated.
[00:07:24] Alyssa Saklak: What about coffee?
[00:07:25] Besa Tole: So hydration.
[00:07:26] Alyssa Saklak: I also love coffee.
[00:07:29] Besa Tole: If they're set up carefully and appropriately, they can be used for beverages, right? So, according to Northwestern Medicine's Workforce Health and Safety Department and the Infection Prevention Department, there are some key requirements. If you're setting up a hydration station, it should always be clearly marked. So either if it's a bin — some mark it with tape, but with tape, you have to be careful because it has to be wipeable, monitored for integrity, and replaced if damaged. So best practice, really, is to have a clean, empty cabinet if available. So you store beverages in there. Those beverages should have a secure lid. And again, just not be near any type of infectious or toxic material, including sharps containers. So, really do an assessment of your area where this should be placed or which cabinets to use, and have some type of hand sanitizer or hand-washing station nearby so you can wash your hands before you get in there. So the goal is to have a clear, separate space from any type of clinical risk. So there's no confusion. But as long as it's in a clean space, they can have beverages there, closed.
[00:08:35] Rene Catalano: And having a lid on a beverage does not immediately eliminate risk. So that is why a hydration station is important, because the lid itself can become contaminated or the sipping area around a tumbler can have an exposure. And then nurses go and drink from it and suddenly have an exposure. I mean, we have things at the workstation like glucometers that can have droplets of blood or dry blood. We have CaviWipes, we have bleach wipes, and we have specimens that may momentarily be at the nurses station prior to them being tubed. So we really have to separate and designate a safe hydration station with only covered drinks. Yeah.
[00:09:16] Laurin Henderson: Good to know. We're a pro-hydration station at Northwestern.
[00:09:19] Alyssa Saklak: I know. I love.
[00:09:20] Besa Tole: Yes, we are.
[00:09:21] Laurin Henderson: Maybe at a higher level, could you tell us a little bit about the different regulatory bodies? And like I said, we're talking about The Joint Commission because I think that's the one that comes to mind the most when we're thinking about the inpatient space. But what is The Joint Commission and how do they impact what we do here at the bedside?
[00:09:38] Rene Catalano: The Joint Commission is actually a deeming authority for CMS, which is the Centers for Medicare & Medicaid Services. Essentially what that means is if we have a Joint Commission survey every three years, then we don't have to have a separate survey by CMS. If an organization meets conditions of participation that are assigned by CMS to all healthcare organizations, they have been deemed accredited organizations. So, essentially, we are surveyed against the CoP, or Conditions of Participation. And for nurses it's a huge impact because, if you think about it, nurses virtually play a part in everything that gets surveyed — everything from patient care, medication management, national performance goals, the environment of care and even parts of facilities management. So even though nurses may not be thinking about accreditation every day, they're absolutely participating in accreditation and manifesting ways to stay compliant.
[00:10:33] Alyssa Saklak: I think that huge responsibility is part of the fear whenever any type of regulatory body comes in, because there's so much responsibility and it takes a team to truly make sure that we're providing safe patient care in the best capacity that we can. I think those exercises that we do to stay prepared have definitely helped to decrease that, like, fear of, "No, we actually have this and we are doing a lot of things." And I feel like that changed for me, but only a couple years into nursing; it took an understanding of that. As a new grad nurse, I was like, "I don't want to be asked a question," and I would run the other way, but now I can see the benefit of that. I guess, for both of you, what are some of the benefits that you've seen just come out of it? And being in the roles that you have, obviously your passion for policies and patient safety, you've probably seen so many different changes. But is there anything in particular that really stands out to you that matters in the work that you do that kind of motivates you?
[00:11:27] Besa Tole: I think my favorite part of my job is to be a scribe. So accreditation managers, all of us go to The Joint Commission surveys at other hospitals and then we are partnered up with a surveyor and we're the scribe. And just listening to nurses, to different leaders, to different ancillary staff talk about what they do every day — it is beautiful. It's so, like, you just get amazed. It's inspiring. It's amazing. And I think, like, The Joint Commission is really trying to change their way of surveying by not just focusing on things like, "You did that wrong," or "You did that wrong." It's more like, "Hey, what quality projects or what projects in general are you doing here?" And the moment you ask, especially a nurse, that they just like — it's like this glow, like, "Oh, we're doing this," or "We're doing that," and it's so amazing to see their motivation. I think that's like my favorite part is just being able to go to all these different units and kind of experiencing like a little bit of what they do during that time or is awesome. It's incredible.
[00:12:26] Rene Catalano: For me, I very much enjoy this role because I view it as a different level of nursing care. I'm used to being a nurse. I was a nurse for so many years. I taught so many classes, so many programs. Even review courses for nurses to become certified in their specialty areas. And when I came here, I thought I would lose that. I thought I would lose that passion to teach, and I'm still teaching — just at a different level, with different subject matter. And what this has allowed me to do is actually also learn, right? Because the saying goes, "It's in learning that you teach and in teaching that you learn." It has allowed me to still have the best of both.
[00:13:05] Laurin Henderson: Besa, earlier you talked about OSHA — like an OSHA standard or an OSHA violation that may have occurred to, like, spur the water bottle myth. Can you talk a little bit about OSHA's role? What does OSHA stand for and how do they impact what we're doing here at Northwestern Medicine?
[00:13:19] Besa Tole: So OSHA stands for Occupational Safety and Health Administration. They're a federal agency under the U.S. Department of Labor. And basically, its job is to protect workers to recognize hazards that could cause either illness, injury, or death.
[00:13:32] Laurin Henderson: Can you speak a little bit to the standards that OSHA and The Joint Commission have, and how maybe sometimes it feels like our internal policies, speaking from the downtown campus obviously, are maybe a little bit more strict than what The Joint Commission or OSHA outlines as the standard?
[00:13:51] Rene Catalano: We try hard at Northwestern Medicine to write our policies to align with regulations. Sometimes they're a little bit more strict because we have to write policies that align with all of our system hospital practices. OK. The important thing to remember is that the CMS regulations are really your minimum requirements. Oftentimes, The Joint Commission is even stricter than CMS. Sometimes our policies might be the strictest, and the general rule is we are held to the strictest regulation. So, if that's our policy, then it's our policy. If it's the Condition of Participation, it's that. The Joint Commission is not very prescriptive. They expect us to follow all federal and state regulations, and they also expect us to follow our own policies. So the rule here is: Try your best to draft policies that align with regulations and follow the strictest rule.
[00:14:48] Alyssa Saklak: I guess that puts both of you as the middle people to interpret those and to make sure that we are aligned with that and there's no gaps or, kind of, inconsistencies, which I can imagine can be really challenging — to have to translate the different regulators to understand which one's the strictest and then make sure that we're aligned with that. And let's add in the different care environments. So, there's obviously both of you, but how many of you work across the system in helping to ensure that each site is compliant in doing this work? Tell me about that.
[00:15:18] Besa Tole: I believe there's seven of us. We're not in the same office space; we talk every day. So, we're all constantly talking to each other about either new regulations or old regulations, constantly reviewing things, kind of picking each other's brains to ensure that we're all reading it the same way because sometimes a standard is so vaguely written that it's hard to interpret. Right. So, we really rely on each other to all of us read it, let's see if we're all thinking the same thing. And if we have any questions, we are able to reach out to The Joint Commission to ask clarifying questions. We use our safety tools, right? Clarifying questions are big. And IDPH — we have a contact there; we'll reach out to them as well if we have any questions because it's important to really understand what they're looking for, right? We don't want to just assume this is what they may be looking for. So, we do ask each other questions as well as regulatory bodies.
[00:16:08] Rene Catalano: If there's ever an opportunity to do something as a system, we seize that opportunity. Always. Standardization is best. We see that across all of our surveys — that once something is standardized across the hospital system, it's so much easier to stay compliant.
[00:16:23] Alyssa Saklak: You mentioned another one, IDPH, and that one's very familiar as well. Can you explain: What is IDPH and their role with all the other regulatory bodies we talked about?
[00:16:33] Besa Tole: IDPH are our state regulators. They have a manual called the State Operations Manual, which essentially aligns with all the Conditions of Participation from the Centers for Medicare and Medicaid Services. Oftentimes, CMS defers to state operations and state regulators to come in and do investigation surveys, especially those related to complaints. So, when IDPH receives a complaint or when CMS receives a complaint, the decision is made who's going to come in and investigate, and it's usually the state survey agency that comes in. So, again, they are authorities for the Centers for Medicare & Medicaid Services.
[00:17:10] Alyssa Saklak: So many checks and balances. I feel like as I talk to you more, I'm like, "I don't know how you keep this all straight." I think our policies and procedures really help us. I feel like in nursing school, they don't really teach to a specific — because obviously each hospital and institution's going to have its own specific policy. But I do think nursing and healthcare workers have such an influence on the environments they work in to advocate. And then those things go through other regulatory bodies to make sure: Can we make these changes? Because the care environment changes so much. I mean, I just think about where Laurin and I are coming up to 10 years here at Northwestern Medicine, but how much it's changed and how many policies have changed to keep up with that.
[00:17:48] Rene Catalano: We are constantly reviewing policies in conjunction with keeping up with the regulatory changes from all of the agencies that we talked about. We get alerts and notices from the Illinois Health and Hospital Association, from IDPH itself, from The Joint Commission, and from CMS. We get memos from CMS. And when regulations change, we have to sit down as a group and determine what our practices are and what our gaps might be, both locally and organizationally. And then we have to decide what needs to be changed — whether it be practices, policies, or all of them. So, that's our job.
[00:18:24] Besa Tole: Frontline staff — they know what they're doing every day, right? And sometimes a policy may be written a certain way, but in practice, it's not happening that way. So, it's also important sometimes to get that frontline review to make sure like, "Hey, this is the policy as it's written, but are we actually able to do it this way?" Right? Like, it can sound beautiful, but in practice, if we're not able to do it, then we have to really evaluate and see, OK, what is practical? What can you guys actually do? So, it's good to have that frontline staff review. And maybe if they're not involved in the review process but do have feedback, it's important to provide that feedback because we don't know; we're not out there, right? And then we are the one who cross-check: Is that still compliant from a regulatory body? Can we make that change in a policy or not? So, we always do those cross-checks, but it's important to get the feedback.
[00:19:15] Rene Catalano: Because as nurses, you know what you can operationalize realistically.
[00:19:18] Laurin Henderson: As managers we're constantly trying to identify those things, crosscheck it with our policy, and then figure out how do we make this easier, better, more efficient for our bedside nurses who are providing our care while still, like we've been talking about, meet these standards that are outlined for
[00:19:18] Laurin Henderson: As managers, we're constantly trying to identify those things, cross-check it with our policy, and then figure out: How do we make this easier, better and more efficient for our bedside nurses who are providing our care while still, like we've been talking about, meeting these standards that are outlined for us?
[00:19:34] Rene Catalano: So, you notice something that needs to be changed because of this sort of assessment and evaluation of our policies. There are means by which you can do that, and that's by first reaching out to stakeholders, subject matter experts, your service line cohorts, and then, of course, touching base with your local policy manager.
[00:19:54] Laurin Henderson: Hopefully people hear that we are seeking that feedback. If something doesn't fit or it doesn't make sense, we wanna know and we wanna make it better and easier because if it helps them, it helps us and it helps you guys.
[00:20:05] Alyssa Saklak: Yeah, I was going to say, I think hearing everyone share their thoughts on it, the transparency piece is so important for the bedside providers so that they understand the "why," because that helps with the buy-in and the change management, but also creates a culture of safety where people feel comfortable to voice, "Hey, like, I understand this is the why, I'm having a hard time because of X, Y and Z." And then we look at the resources and creative solutions that we can come up with. And then, when we get audited or have these regulatory bodies, we're always — I feel like there's a different sense of us just wanting to get better. We want them to come in and tell us where our gaps are. Obviously, we want it to be manageable and not to be an egregious finding, but we also understand that their job is to come and find stuff. And so, that is OK. I've heard, Rene, you've spoken many a times to the safety metrics and findings and how that works because, to Laurin's point in the beginning of the conversation, one finding of a drink in the wrong area doesn't mean the whole hospital's going to be closed down. And I think that's our fear. Like, I think about things like, "I'm going to be the one person that shuts the whole hospital down," or "I say one thing incorrectly and I didn't do my job." Like, that's the worst fear. But there's more to it.
[00:21:13] Rene Catalano: If you can think of it as The Joint Commission being here as collaborators and, as Besa put it, not the "police" of the hospital, but as collaborators to identify risk points for us, that just promotes safety and quality. I mean, that's the goal here — to be in a constant state of improvement. And if we can look at our regulatory bodies as collaborators, then we can be grateful for them identifying our risk points before anything reaches a patient that shouldn't. The reason these regulations are in place is because things have happened, harm has happened, and so from these trends that our regulators see across the nation, across the globe, that's where the standards and regulations come from — events that have truly happened in the field and why we have to protect ourselves and our patients.
[00:22:05] Besa Tole: Alyssa, as you were saying, like, we strive to be better, right? So, when The Joint Commission points out that we're doing something maybe incorrectly or one of our risk points, then we have to create an action plan. We have to do something to make it better. So, it's OK to have a finding. I think people are just scared to have a finding in their unit. They're like, "We want to be at the unit with no findings at all," which is great, but I personally want that to make sure that they had a good, valuable survey and they learned from it, right? So, if they did have a finding, even if it's a minor one or a major one, it's OK because the whole point of it is to then create an action plan and then fix it.
[00:22:41] Laurin Henderson: The surprise factor of these regulatory bodies coming in. And then managers get a Teams message from Rene Catalano with the red exclamation point that says the surveyors have arrived. And we're all like, "Here we go." I think I understand the purpose, but can you explain a little bit? They give us a window where they potentially can come at any time. And then what — like, what's the purpose of that and how are you notified when that window opens, closes, or when they're going to come?
[00:23:06] Rene Catalano: That's the surprise factor. So let me open this by asking the nurses a question: Would you give your patient a medication without performing the seven rights of medication administration? No. So we don't ramp up and just do that when The Joint Commission is coming; we do it every day, right? The Joint Commission does not want to survey us while we are in prep mode. They want to survey us with our day-to-day practices because that's where they're going to find the risk points. OK. And we'd love to find our own risk points, and we do a really good job of that through tracers, through audits, your pain audits, your restraint audits. We do a really good job at identifying our risk points, but The Joint Commission does not want to announce their presence so that everybody decides, "Now I'm going to do the right thing because The Joint Commission is coming." We want to be surveyed honestly, transparently and collaboratively using our day-to-day practices, which we know are very sound, very compliant, and very good and high quality. So, that's the surprise factor. And the window opens six months before the due date. It used to be 18 months; now it is six months. So, of course, the reality is we're going to tighten things up in the six months prior, but we really should be practicing every single day to the standards and to the regulations.
[00:24:30] Alyssa Saklak: You also don't know why they're visiting, correct?
[00:24:34] Rene Catalano: Right? We don't know.
[00:24:35] Alyssa Saklak: If it's a focused visit, we will know, like, whether it's blood products or lab or wherever. And the scheduled ones are, kind of, the annual ones. But that, I think, is also part of the mystery — that you're kind of like, "OK, what are they here for?" And we don't really know that upfront.
[00:24:51] Laurin Henderson: Adrenaline rush that Besa loves.
[00:24:53] Besa Tole: Yeah, I would say we don't know either. We don't know until they show up at our front door and we get a phone call from the front desk. So, it is an adrenaline rush.
[00:25:00] Laurin Henderson: Yeah. Not allowed to disclose the details of the complaint.
[00:25:03] Besa Tole: We can gather from the complaint which condition they're surveying to. We can make certain assumptions that way. At times, they will tell you the condition that they're surveying, like if it's EMTALA or patient rights or nursing. But we are not made aware of the details of the complaint. Yeah.
[00:25:21] Alyssa Saklak: That's true for like the whole — I mean, and I guess to your point, like, you may be able to gather and put together a theory of what you believed the complaint was related to, but throughout the whole experience, they never disclose the full issue, do they?
[00:25:35] Rene Catalano: They do not. They do not. And they have to survey to the entire condition. So even if we can make an assumption that a patient complained about the care they received — the nursing care or the pain management — well, now we know we're in the patient rights Condition of Participation. So, now they're going to look at everything: Nets reports, grievances, patient charts, nursing care. They're going to look at the entire condition. So, they may have a finding that's completely unrelated. And they have to survey to the entire condition. So even if we can make an assumption that a patient complained about the care they received, the nursing care, or the pain management, well now we know we're in the patient rights condition of participation. So now they're gonna look at everything. NETS reports, grievances, patient charts, nursing care. They're gonna look at the entire condition. So they may have a finding that's completely unrelated to.
[00:26:03] Laurin Henderson: That's not my type of excitement.
[00:26:06] Alyssa Saklak: I was going to say, and what's the typical length? I feel like it's usually a full week, like three or four days. What's the longest visit that you've had in your experience?
[00:26:14] Besa Tole: I think the five days at Northwestern Memorial for The Joint Commission. But usually, the other hospitals have a four-day Joint Commission triennial survey because of the size. So, depending on the size and complexity, it'll change. And then IDPH, depending on what's happening, too — it's usually three days, but it could be two. I mean, again, it depends on how many complaints. Sometimes they roll a couple complaints together, and they come in for more than one.
[00:26:39] Alyssa Saklak: Once the person or the auditors have left, can they continue to ask for supporting evidence or more information, or does it usually close when they do the closing?
[00:26:47] Besa Tole: It closes when they do the closing. Unless they — like, if we have to submit anything. So if we did get a finding and then we have to submit our action plan or maybe a policy change, they can ask for more information within that action plan.
[00:27:00] Laurin Henderson: What advice would you give to a nurse specifically who knows that a surveyor from a regulatory body is coming to their area and it's their first time interacting? What advice would you give to them? How would you encourage them that it's going to be OK?
[00:27:15] Rene Catalano: Well, The Joint Commission does a very good job at reminding nurses that they are here to collaborate. They come in peace. They want to work with nurses to understand processes, and so nurses can feel confident answering the questions that are asked. What we don't recommend is expounding or embellishing answers. Just be honest to your processes. Answer the questions that are asked without offering additional information, and answer with confidence. That is key because nurses know how to be compliant. They do this every day, and they should be able to showcase their good work. And, of course, this is not a time to challenge standards. There is a mechanism by which we can challenge standards or findings after the survey. This is a time for nurses to be collaborative with surveyors.
[00:28:07] Besa Tole: If you don't know the answer, it's OK. Don't say, "I don't know," and then stare. Be like, "Oh, that's a great question. Let me find out. Let me ask my manager. I can pull up a policy." Whatever you need to do to take that next step to find an answer, that's where you go. A lot of times people are more nervous because they think they're going to be asked something that they don't know the answer to or they cannot confidently speak to it. And it's OK to use your resources; that's why we have them. So, it's nerve-wracking, but it's a good adrenaline rush, right? Like, think of it like you know what you're doing. You do this every day. It's not something different. And you have a whole team to support you there. You're never going to be alone for the surveyor. You have a team there — use them.
[00:28:48] Alyssa Saklak: You're never alone in patient care, so that mocks that. Exactly. And it is an open-book quiz; like, you have those resources that you can use. Yeah. Yeah. I love that.
[00:28:58] Rene Catalano: Think of it like knowledge being of two kinds: That which you know, and that which you know where to find. That's it. Knowledge is what you know, but it's also knowing where to find answers.
[00:29:08] Laurin Henderson: I'm gonna use that.
[00:29:09] Alyssa Saklak: I'm hoping we didn't jinx ourselves with recording this episode, but if so, I feel prepared and confident and you've answered all my questions regarding that. So, thank you so much, Besa and Rene, for joining us today, busting some of these myths, and just enlightening us on this process for better patient care.
[00:29:26] Rene Catalano: Thank you for having us.
[00:29:27] Laurin Henderson: Thank you both.
[00:29:33] Laurin Henderson: Thank you for listening. Please follow us wherever you get your podcasts, and rate and review the show.
[00:29:38] Alyssa Saklak: We'd love to hear your comments and any topics you might want us to explore.
[00:00:02] Laurin Henderson: And I'm Laurin Henderson.
[00:00:03] Alyssa Saklak: On Better RN, we get real about nursing,
[00:00:06] Laurin: The good and the gritty.
[00:00:08] Alyssa Saklak: We talk to real healthcare experts.
[00:00:10] Laurin: With the goal of becoming better
[00:00:12] Alyssa Saklak: For our patients, our colleagues,
[00:00:14] Laurin: Our family, our friends,
[00:00:16] Alyssa Saklak: Our partners, and ourselves.
[00:00:20] Laurin Henderson: Hi, Alyssa.
[00:00:21] Alyssa Saklak: Hi, Laurin.
[00:00:22] Laurin Henderson: I'm excited for today's episode; we're talking to two Northwestern Medicine employees today about all things regulatory.
[00:00:30] Alyssa Saklak: I feel like my heart pitter-patters a little bit quicker whenever I feel like I am being put on the spot in front of an accreditor, and it's scary.
[00:00:37] Laurin Henderson: I remember my first time as a manager when we had surveyors in-house, and you think that it's going to be me that shuts this place down for something silly. But that's actually not the case. And Rene Catalano and Besa Tole are going to talk to us today about how actually a lot of these regulatory bodies want to work with us. They want to make things better and they want to find our weak spots so that we can improve and do better for our patients and our staff.
[00:01:01] Alyssa Saklak: And I think that Northwestern Medicine has a lot in place to make sure that we're successful to break down some of the fear, myths, and stigma around what it means to be a bedside healthcare provider and have someone come in and question your policies, procedures, and standards of care.
[00:01:18] Laurin Henderson: They talk about this specific type of adrenaline rush that they get from doing this certain type of work, which, to each their own. It's not my kind of adrenaline, but I'm very glad that we have people that love this work.
[00:01:30] Alyssa Saklak: We are so lucky, and Northwestern Medicine is a large healthcare system and there's different sites that have different complex environments. And so there's a lot of care that we standardize on that we do across the system, and each site has its unique challenges. But I think it's fascinating the work that they do and the tremendous amount of governing bodies that are the checks and balances of healthcare and hospital systems. And how do we fit into the mix and how do we advocate for the things that we need in our care environments?
[00:01:59] Laurin Henderson: And what's real and what's not.
[00:02:00] Alyssa Saklak: And the biggest myth of all: Is water really against the rules in the nurses station?
[00:02:06] Laurin Henderson: For years a lot of people felt like drinking water at the nurses station was somehow against the rules and having a water bottle at the nurses station was going to shut the place down and get us cited by The Joint Commission, which is the independent organization that accredits and certifies thousands of hospitals across the country, and the one that we, I think, focus on the most today in our conversation. However, they have publicly addressed that issue, saying that no, water at the nurses station is not their rule; it's actually a myth. So where did this idea come from? Who decides whether you can have water at your workstation? And Rene and Besa help us suss this out.
[00:02:39] Rene Catalano: Thank you for having us.
[00:02:41] Laurin Henderson: Well, thank you both for coming on the podcast. Tell us a little bit about yourselves, who you are, and your role here at Northwestern Medicine.
[00:02:48] Besa Tole: My name is Besa Tole. I am the accreditation, clinical compliance, and policy management manager at Northwestern Medicine's Central DuPage Hospital. I have a lab background, actually, and I've been here almost 14 years —14 years in September.
[00:03:02] Rene Catalano: And I'm Rene Catalano. I hold the same title at Northwestern Memorial Hospital downtown. And my background is as a critical care nurse for 25 years here downtown, and I was also an education coordinator for 19 of those years. I've been at Northwestern Medicine going into my 39th year in August.
[00:03:22] Laurin Henderson: Well, we're really happy that you both agreed to come talk with us today. When we're talking about The Joint Commission and regulatory bodies, obviously Alyssa and I are nurses by background, so those are like black clouds to us. We don't love to hear that those people are coming. What got you interested in going into this line of work within your nursing and your lab background? How did you get to this spot?
[00:03:48] Rene Catalano: Well, I was an education coordinator and a critical care nurse for many years and just wore different hats in that role — just even as a resource coordinator at one point as a clinical practice consultant. And I pretty much had my dream job. But I wanted to get more in touch with the "why" behind all of the hospital regulations, and that drove me to seek a position within the quality department and accreditation as part of that. And it's been a lot of years of learning, but understanding hospital policy and understanding regulators that come in and evaluate hospitals and the reasons why we have these regulations has really fostered a new appreciation for me as a nurse.
[00:04:32] Laurin Henderson: Besa, would you say you've had a similar path?
[00:04:34] Besa Tole: Well, I was the lab educator and the point-of-care coordinator, and that actually fell under quality in the lab. And it was kind of an adrenaline rush when we had CAP inspections, and I liked it. So it was interesting to kind of get the hospital side of regulatory and quality. So it was kind of, in a way for me, a fun path to go because I am not a nurse, so it's a huge learning curve. But it's been fun.
[00:04:58] Alyssa Saklak: I love that you described it as like an adrenaline rush, because I feel like that's the perfect way to describe it. And I very vividly remember some of the first — I would call it our "houseguest" — whether it was an auditor of The Joint Commission or CMS. But when I walked in and Rene was sitting there and I was being pulled to, like, help with this, Rene, you had such a calm to you. And I internally was panicking, like, "Am I going to say the right thing?" "Did we do the right thing?" You are the stabilizer when we are being put to review these things. So, thank you for that.
[00:05:33] Besa Tole: Of course, a team. We're calm on the outside, but on the inside, we feel the same way.
[00:05:39] Laurin Henderson: I think that's the half of it, right? Just putting on a bold face. But when any regulatory body for any sort of survey comes in, I think nursing gets a little on edge because we know we're doing good work and we know we're doing the right thing. But there are these myths that have made it to the bedside somehow that The Joint Commission specifically is coming in and looking for water bottles. They want to see 'em at the nurses station and they want to cite us for it. Can you talk a little bit about the idea that is their "bread and butter"? They're just looking for the water bottles. Where did that idea come from and is it true? Is that a Joint Commission rule that you can't drink water at the nurses station?
[00:06:17] Besa Tole: So, we think the myth may have started because of a simple misunderstanding, right? So if one regulatory body prohibits drinks from certain work areas, then people just assume all regulatory bodies must prohibit them everywhere. So, really, that's not the case. There was most likely some type of OSHA citation at one point that there were drinks near some chemicals or potentially infectious material, or maybe somebody actually got, like, hurt from it — there was a true exposure. That kind of led people to this broad conclusion that drinks at a workstation are universally banned. So, it is a myth, and social media loves to play on that. So we've kind of seen that Nurse Blake comedy bit with The Joint Commission pointing at water. The nursing station is really funny, but it's really a misconception. So, they're trying to clear it up; it's not a true standard.
[00:07:03] Laurin Henderson: So they don't want nurses to be dehydrated is what you're saying. Perfect. OK. That, if anything from this episode.
[00:07:15] Besa Tole: Exactly.
[00:07:16] Laurin Henderson: Talk to us about hydration stations. What does that mean? What's the concept? Why do we --
[00:07:20] Besa Tole: Yeah. I mean, we want water, right? Like, everybody needs to be hydrated.
[00:07:24] Alyssa Saklak: What about coffee?
[00:07:25] Besa Tole: So hydration.
[00:07:26] Alyssa Saklak: I also love coffee.
[00:07:29] Besa Tole: If they're set up carefully and appropriately, they can be used for beverages, right? So, according to Northwestern Medicine's Workforce Health and Safety Department and the Infection Prevention Department, there are some key requirements. If you're setting up a hydration station, it should always be clearly marked. So either if it's a bin — some mark it with tape, but with tape, you have to be careful because it has to be wipeable, monitored for integrity, and replaced if damaged. So best practice, really, is to have a clean, empty cabinet if available. So you store beverages in there. Those beverages should have a secure lid. And again, just not be near any type of infectious or toxic material, including sharps containers. So, really do an assessment of your area where this should be placed or which cabinets to use, and have some type of hand sanitizer or hand-washing station nearby so you can wash your hands before you get in there. So the goal is to have a clear, separate space from any type of clinical risk. So there's no confusion. But as long as it's in a clean space, they can have beverages there, closed.
[00:08:35] Rene Catalano: And having a lid on a beverage does not immediately eliminate risk. So that is why a hydration station is important, because the lid itself can become contaminated or the sipping area around a tumbler can have an exposure. And then nurses go and drink from it and suddenly have an exposure. I mean, we have things at the workstation like glucometers that can have droplets of blood or dry blood. We have CaviWipes, we have bleach wipes, and we have specimens that may momentarily be at the nurses station prior to them being tubed. So we really have to separate and designate a safe hydration station with only covered drinks. Yeah.
[00:09:16] Laurin Henderson: Good to know. We're a pro-hydration station at Northwestern.
[00:09:19] Alyssa Saklak: I know. I love.
[00:09:20] Besa Tole: Yes, we are.
[00:09:21] Laurin Henderson: Maybe at a higher level, could you tell us a little bit about the different regulatory bodies? And like I said, we're talking about The Joint Commission because I think that's the one that comes to mind the most when we're thinking about the inpatient space. But what is The Joint Commission and how do they impact what we do here at the bedside?
[00:09:38] Rene Catalano: The Joint Commission is actually a deeming authority for CMS, which is the Centers for Medicare & Medicaid Services. Essentially what that means is if we have a Joint Commission survey every three years, then we don't have to have a separate survey by CMS. If an organization meets conditions of participation that are assigned by CMS to all healthcare organizations, they have been deemed accredited organizations. So, essentially, we are surveyed against the CoP, or Conditions of Participation. And for nurses it's a huge impact because, if you think about it, nurses virtually play a part in everything that gets surveyed — everything from patient care, medication management, national performance goals, the environment of care and even parts of facilities management. So even though nurses may not be thinking about accreditation every day, they're absolutely participating in accreditation and manifesting ways to stay compliant.
[00:10:33] Alyssa Saklak: I think that huge responsibility is part of the fear whenever any type of regulatory body comes in, because there's so much responsibility and it takes a team to truly make sure that we're providing safe patient care in the best capacity that we can. I think those exercises that we do to stay prepared have definitely helped to decrease that, like, fear of, "No, we actually have this and we are doing a lot of things." And I feel like that changed for me, but only a couple years into nursing; it took an understanding of that. As a new grad nurse, I was like, "I don't want to be asked a question," and I would run the other way, but now I can see the benefit of that. I guess, for both of you, what are some of the benefits that you've seen just come out of it? And being in the roles that you have, obviously your passion for policies and patient safety, you've probably seen so many different changes. But is there anything in particular that really stands out to you that matters in the work that you do that kind of motivates you?
[00:11:27] Besa Tole: I think my favorite part of my job is to be a scribe. So accreditation managers, all of us go to The Joint Commission surveys at other hospitals and then we are partnered up with a surveyor and we're the scribe. And just listening to nurses, to different leaders, to different ancillary staff talk about what they do every day — it is beautiful. It's so, like, you just get amazed. It's inspiring. It's amazing. And I think, like, The Joint Commission is really trying to change their way of surveying by not just focusing on things like, "You did that wrong," or "You did that wrong." It's more like, "Hey, what quality projects or what projects in general are you doing here?" And the moment you ask, especially a nurse, that they just like — it's like this glow, like, "Oh, we're doing this," or "We're doing that," and it's so amazing to see their motivation. I think that's like my favorite part is just being able to go to all these different units and kind of experiencing like a little bit of what they do during that time or is awesome. It's incredible.
[00:12:26] Rene Catalano: For me, I very much enjoy this role because I view it as a different level of nursing care. I'm used to being a nurse. I was a nurse for so many years. I taught so many classes, so many programs. Even review courses for nurses to become certified in their specialty areas. And when I came here, I thought I would lose that. I thought I would lose that passion to teach, and I'm still teaching — just at a different level, with different subject matter. And what this has allowed me to do is actually also learn, right? Because the saying goes, "It's in learning that you teach and in teaching that you learn." It has allowed me to still have the best of both.
[00:13:05] Laurin Henderson: Besa, earlier you talked about OSHA — like an OSHA standard or an OSHA violation that may have occurred to, like, spur the water bottle myth. Can you talk a little bit about OSHA's role? What does OSHA stand for and how do they impact what we're doing here at Northwestern Medicine?
[00:13:19] Besa Tole: So OSHA stands for Occupational Safety and Health Administration. They're a federal agency under the U.S. Department of Labor. And basically, its job is to protect workers to recognize hazards that could cause either illness, injury, or death.
[00:13:32] Laurin Henderson: Can you speak a little bit to the standards that OSHA and The Joint Commission have, and how maybe sometimes it feels like our internal policies, speaking from the downtown campus obviously, are maybe a little bit more strict than what The Joint Commission or OSHA outlines as the standard?
[00:13:51] Rene Catalano: We try hard at Northwestern Medicine to write our policies to align with regulations. Sometimes they're a little bit more strict because we have to write policies that align with all of our system hospital practices. OK. The important thing to remember is that the CMS regulations are really your minimum requirements. Oftentimes, The Joint Commission is even stricter than CMS. Sometimes our policies might be the strictest, and the general rule is we are held to the strictest regulation. So, if that's our policy, then it's our policy. If it's the Condition of Participation, it's that. The Joint Commission is not very prescriptive. They expect us to follow all federal and state regulations, and they also expect us to follow our own policies. So the rule here is: Try your best to draft policies that align with regulations and follow the strictest rule.
[00:14:48] Alyssa Saklak: I guess that puts both of you as the middle people to interpret those and to make sure that we are aligned with that and there's no gaps or, kind of, inconsistencies, which I can imagine can be really challenging — to have to translate the different regulators to understand which one's the strictest and then make sure that we're aligned with that. And let's add in the different care environments. So, there's obviously both of you, but how many of you work across the system in helping to ensure that each site is compliant in doing this work? Tell me about that.
[00:15:18] Besa Tole: I believe there's seven of us. We're not in the same office space; we talk every day. So, we're all constantly talking to each other about either new regulations or old regulations, constantly reviewing things, kind of picking each other's brains to ensure that we're all reading it the same way because sometimes a standard is so vaguely written that it's hard to interpret. Right. So, we really rely on each other to all of us read it, let's see if we're all thinking the same thing. And if we have any questions, we are able to reach out to The Joint Commission to ask clarifying questions. We use our safety tools, right? Clarifying questions are big. And IDPH — we have a contact there; we'll reach out to them as well if we have any questions because it's important to really understand what they're looking for, right? We don't want to just assume this is what they may be looking for. So, we do ask each other questions as well as regulatory bodies.
[00:16:08] Rene Catalano: If there's ever an opportunity to do something as a system, we seize that opportunity. Always. Standardization is best. We see that across all of our surveys — that once something is standardized across the hospital system, it's so much easier to stay compliant.
[00:16:23] Alyssa Saklak: You mentioned another one, IDPH, and that one's very familiar as well. Can you explain: What is IDPH and their role with all the other regulatory bodies we talked about?
[00:16:33] Besa Tole: IDPH are our state regulators. They have a manual called the State Operations Manual, which essentially aligns with all the Conditions of Participation from the Centers for Medicare and Medicaid Services. Oftentimes, CMS defers to state operations and state regulators to come in and do investigation surveys, especially those related to complaints. So, when IDPH receives a complaint or when CMS receives a complaint, the decision is made who's going to come in and investigate, and it's usually the state survey agency that comes in. So, again, they are authorities for the Centers for Medicare & Medicaid Services.
[00:17:10] Alyssa Saklak: So many checks and balances. I feel like as I talk to you more, I'm like, "I don't know how you keep this all straight." I think our policies and procedures really help us. I feel like in nursing school, they don't really teach to a specific — because obviously each hospital and institution's going to have its own specific policy. But I do think nursing and healthcare workers have such an influence on the environments they work in to advocate. And then those things go through other regulatory bodies to make sure: Can we make these changes? Because the care environment changes so much. I mean, I just think about where Laurin and I are coming up to 10 years here at Northwestern Medicine, but how much it's changed and how many policies have changed to keep up with that.
[00:17:48] Rene Catalano: We are constantly reviewing policies in conjunction with keeping up with the regulatory changes from all of the agencies that we talked about. We get alerts and notices from the Illinois Health and Hospital Association, from IDPH itself, from The Joint Commission, and from CMS. We get memos from CMS. And when regulations change, we have to sit down as a group and determine what our practices are and what our gaps might be, both locally and organizationally. And then we have to decide what needs to be changed — whether it be practices, policies, or all of them. So, that's our job.
[00:18:24] Besa Tole: Frontline staff — they know what they're doing every day, right? And sometimes a policy may be written a certain way, but in practice, it's not happening that way. So, it's also important sometimes to get that frontline review to make sure like, "Hey, this is the policy as it's written, but are we actually able to do it this way?" Right? Like, it can sound beautiful, but in practice, if we're not able to do it, then we have to really evaluate and see, OK, what is practical? What can you guys actually do? So, it's good to have that frontline staff review. And maybe if they're not involved in the review process but do have feedback, it's important to provide that feedback because we don't know; we're not out there, right? And then we are the one who cross-check: Is that still compliant from a regulatory body? Can we make that change in a policy or not? So, we always do those cross-checks, but it's important to get the feedback.
[00:19:15] Rene Catalano: Because as nurses, you know what you can operationalize realistically.
[00:19:18] Laurin Henderson: As managers we're constantly trying to identify those things, crosscheck it with our policy, and then figure out how do we make this easier, better, more efficient for our bedside nurses who are providing our care while still, like we've been talking about, meet these standards that are outlined for
[00:19:18] Laurin Henderson: As managers, we're constantly trying to identify those things, cross-check it with our policy, and then figure out: How do we make this easier, better and more efficient for our bedside nurses who are providing our care while still, like we've been talking about, meeting these standards that are outlined for us?
[00:19:34] Rene Catalano: So, you notice something that needs to be changed because of this sort of assessment and evaluation of our policies. There are means by which you can do that, and that's by first reaching out to stakeholders, subject matter experts, your service line cohorts, and then, of course, touching base with your local policy manager.
[00:19:54] Laurin Henderson: Hopefully people hear that we are seeking that feedback. If something doesn't fit or it doesn't make sense, we wanna know and we wanna make it better and easier because if it helps them, it helps us and it helps you guys.
[00:20:05] Alyssa Saklak: Yeah, I was going to say, I think hearing everyone share their thoughts on it, the transparency piece is so important for the bedside providers so that they understand the "why," because that helps with the buy-in and the change management, but also creates a culture of safety where people feel comfortable to voice, "Hey, like, I understand this is the why, I'm having a hard time because of X, Y and Z." And then we look at the resources and creative solutions that we can come up with. And then, when we get audited or have these regulatory bodies, we're always — I feel like there's a different sense of us just wanting to get better. We want them to come in and tell us where our gaps are. Obviously, we want it to be manageable and not to be an egregious finding, but we also understand that their job is to come and find stuff. And so, that is OK. I've heard, Rene, you've spoken many a times to the safety metrics and findings and how that works because, to Laurin's point in the beginning of the conversation, one finding of a drink in the wrong area doesn't mean the whole hospital's going to be closed down. And I think that's our fear. Like, I think about things like, "I'm going to be the one person that shuts the whole hospital down," or "I say one thing incorrectly and I didn't do my job." Like, that's the worst fear. But there's more to it.
[00:21:13] Rene Catalano: If you can think of it as The Joint Commission being here as collaborators and, as Besa put it, not the "police" of the hospital, but as collaborators to identify risk points for us, that just promotes safety and quality. I mean, that's the goal here — to be in a constant state of improvement. And if we can look at our regulatory bodies as collaborators, then we can be grateful for them identifying our risk points before anything reaches a patient that shouldn't. The reason these regulations are in place is because things have happened, harm has happened, and so from these trends that our regulators see across the nation, across the globe, that's where the standards and regulations come from — events that have truly happened in the field and why we have to protect ourselves and our patients.
[00:22:05] Besa Tole: Alyssa, as you were saying, like, we strive to be better, right? So, when The Joint Commission points out that we're doing something maybe incorrectly or one of our risk points, then we have to create an action plan. We have to do something to make it better. So, it's OK to have a finding. I think people are just scared to have a finding in their unit. They're like, "We want to be at the unit with no findings at all," which is great, but I personally want that to make sure that they had a good, valuable survey and they learned from it, right? So, if they did have a finding, even if it's a minor one or a major one, it's OK because the whole point of it is to then create an action plan and then fix it.
[00:22:41] Laurin Henderson: The surprise factor of these regulatory bodies coming in. And then managers get a Teams message from Rene Catalano with the red exclamation point that says the surveyors have arrived. And we're all like, "Here we go." I think I understand the purpose, but can you explain a little bit? They give us a window where they potentially can come at any time. And then what — like, what's the purpose of that and how are you notified when that window opens, closes, or when they're going to come?
[00:23:06] Rene Catalano: That's the surprise factor. So let me open this by asking the nurses a question: Would you give your patient a medication without performing the seven rights of medication administration? No. So we don't ramp up and just do that when The Joint Commission is coming; we do it every day, right? The Joint Commission does not want to survey us while we are in prep mode. They want to survey us with our day-to-day practices because that's where they're going to find the risk points. OK. And we'd love to find our own risk points, and we do a really good job of that through tracers, through audits, your pain audits, your restraint audits. We do a really good job at identifying our risk points, but The Joint Commission does not want to announce their presence so that everybody decides, "Now I'm going to do the right thing because The Joint Commission is coming." We want to be surveyed honestly, transparently and collaboratively using our day-to-day practices, which we know are very sound, very compliant, and very good and high quality. So, that's the surprise factor. And the window opens six months before the due date. It used to be 18 months; now it is six months. So, of course, the reality is we're going to tighten things up in the six months prior, but we really should be practicing every single day to the standards and to the regulations.
[00:24:30] Alyssa Saklak: You also don't know why they're visiting, correct?
[00:24:34] Rene Catalano: Right? We don't know.
[00:24:35] Alyssa Saklak: If it's a focused visit, we will know, like, whether it's blood products or lab or wherever. And the scheduled ones are, kind of, the annual ones. But that, I think, is also part of the mystery — that you're kind of like, "OK, what are they here for?" And we don't really know that upfront.
[00:24:51] Laurin Henderson: Adrenaline rush that Besa loves.
[00:24:53] Besa Tole: Yeah, I would say we don't know either. We don't know until they show up at our front door and we get a phone call from the front desk. So, it is an adrenaline rush.
[00:25:00] Laurin Henderson: Yeah. Not allowed to disclose the details of the complaint.
[00:25:03] Besa Tole: We can gather from the complaint which condition they're surveying to. We can make certain assumptions that way. At times, they will tell you the condition that they're surveying, like if it's EMTALA or patient rights or nursing. But we are not made aware of the details of the complaint. Yeah.
[00:25:21] Alyssa Saklak: That's true for like the whole — I mean, and I guess to your point, like, you may be able to gather and put together a theory of what you believed the complaint was related to, but throughout the whole experience, they never disclose the full issue, do they?
[00:25:35] Rene Catalano: They do not. They do not. And they have to survey to the entire condition. So even if we can make an assumption that a patient complained about the care they received — the nursing care or the pain management — well, now we know we're in the patient rights Condition of Participation. So, now they're going to look at everything: Nets reports, grievances, patient charts, nursing care. They're going to look at the entire condition. So, they may have a finding that's completely unrelated. And they have to survey to the entire condition. So even if we can make an assumption that a patient complained about the care they received, the nursing care, or the pain management, well now we know we're in the patient rights condition of participation. So now they're gonna look at everything. NETS reports, grievances, patient charts, nursing care. They're gonna look at the entire condition. So they may have a finding that's completely unrelated to.
[00:26:03] Laurin Henderson: That's not my type of excitement.
[00:26:06] Alyssa Saklak: I was going to say, and what's the typical length? I feel like it's usually a full week, like three or four days. What's the longest visit that you've had in your experience?
[00:26:14] Besa Tole: I think the five days at Northwestern Memorial for The Joint Commission. But usually, the other hospitals have a four-day Joint Commission triennial survey because of the size. So, depending on the size and complexity, it'll change. And then IDPH, depending on what's happening, too — it's usually three days, but it could be two. I mean, again, it depends on how many complaints. Sometimes they roll a couple complaints together, and they come in for more than one.
[00:26:39] Alyssa Saklak: Once the person or the auditors have left, can they continue to ask for supporting evidence or more information, or does it usually close when they do the closing?
[00:26:47] Besa Tole: It closes when they do the closing. Unless they — like, if we have to submit anything. So if we did get a finding and then we have to submit our action plan or maybe a policy change, they can ask for more information within that action plan.
[00:27:00] Laurin Henderson: What advice would you give to a nurse specifically who knows that a surveyor from a regulatory body is coming to their area and it's their first time interacting? What advice would you give to them? How would you encourage them that it's going to be OK?
[00:27:15] Rene Catalano: Well, The Joint Commission does a very good job at reminding nurses that they are here to collaborate. They come in peace. They want to work with nurses to understand processes, and so nurses can feel confident answering the questions that are asked. What we don't recommend is expounding or embellishing answers. Just be honest to your processes. Answer the questions that are asked without offering additional information, and answer with confidence. That is key because nurses know how to be compliant. They do this every day, and they should be able to showcase their good work. And, of course, this is not a time to challenge standards. There is a mechanism by which we can challenge standards or findings after the survey. This is a time for nurses to be collaborative with surveyors.
[00:28:07] Besa Tole: If you don't know the answer, it's OK. Don't say, "I don't know," and then stare. Be like, "Oh, that's a great question. Let me find out. Let me ask my manager. I can pull up a policy." Whatever you need to do to take that next step to find an answer, that's where you go. A lot of times people are more nervous because they think they're going to be asked something that they don't know the answer to or they cannot confidently speak to it. And it's OK to use your resources; that's why we have them. So, it's nerve-wracking, but it's a good adrenaline rush, right? Like, think of it like you know what you're doing. You do this every day. It's not something different. And you have a whole team to support you there. You're never going to be alone for the surveyor. You have a team there — use them.
[00:28:48] Alyssa Saklak: You're never alone in patient care, so that mocks that. Exactly. And it is an open-book quiz; like, you have those resources that you can use. Yeah. Yeah. I love that.
[00:28:58] Rene Catalano: Think of it like knowledge being of two kinds: That which you know, and that which you know where to find. That's it. Knowledge is what you know, but it's also knowing where to find answers.
[00:29:08] Laurin Henderson: I'm gonna use that.
[00:29:09] Alyssa Saklak: I'm hoping we didn't jinx ourselves with recording this episode, but if so, I feel prepared and confident and you've answered all my questions regarding that. So, thank you so much, Besa and Rene, for joining us today, busting some of these myths, and just enlightening us on this process for better patient care.
[00:29:26] Rene Catalano: Thank you for having us.
[00:29:27] Laurin Henderson: Thank you both.
[00:29:33] Laurin Henderson: Thank you for listening. Please follow us wherever you get your podcasts, and rate and review the show.
[00:29:38] Alyssa Saklak: We'd love to hear your comments and any topics you might want us to explore.