The new survey process will surprise you

Are you spending hundreds of hours, hiring expensive consultants, and holding countless meetings preparing staff for every survey from the Joint Commission on Accreditation of Healthcare Organizations? April Dukes, RN, head nurse for the ED at Tift Regional Medical Center in Tifton, GA, echoes the sentiments of most ED managers when she says that getting ready for Joint Commission surveys often is viewed as "a total nightmare."

That soon may change as a result of dramatic changes in the way the organization will conduct surveys as of 2004, with self-assessments to be distributed beginning in mid-2003. According to the Joint Commission, there will be more of a focus on safety and quality patient care, and less frantic "ramping up" before surveys.

Dukes recently got an advance look at the new survey process when her ED participated in a pilot test of the new process with the Joint Commission. Surveyors were more focused on overall patient care instead of individual standards, which resulted in fewer last-minute preparations, she reports. "As a manager, if I stay compliant with the big issues and can enforce that every day, surveys are not as overwhelming," she says.

ED managers interviewed think that this new process is a positive change. "This will guarantee that patients are receiving high standards of care 100% of the time, not only during survey time," says Karen Clements, RN, BSN, ED nurse manager at Eastern Maine Medical Center in Bangor.

"The focus has definitely changed," says Kathryn Perlman, MS, RN, CEN, clinical specialist for the ED at Presbyterian Hospital of Dallas. "What we are being told is that the surveyors [now] come with two guns; one loaded with patient safety and the other loaded with error reporting," she says.

Clements says she plans to begin informing staff about the new survey process shortly. "The new requirements will be passed on to my charge nurses and to my staff educators to reach their core group that fall under them," she says. "This helps disseminate information, especially on off-shifts."

Perlman attended an all-day workshop for her facility’s educators and managers on the new survey process, and ED staff soon will be inserviced with learning modules and handouts.

Here are key areas that surveys will focus on:

Quality patient care. Clements says that her ED has been working on a daily survey mentality for some time. "I sincerely believe that supporting behaviors on a daily basis that support excellent standards of care is more efficient than ramping up for Joint Commission, and also better for the patients and their families," she says. If expectations for quality care are always there, things only need tweaking before surveys, she explains.

To demonstrate continuous quality improvement, Clements says her ED is developing "dashboard" data so staff can track what’s going on with the overall department. "We are already using computers for patient tracking, and we would like to incorporate real-time data on length of stay and delays," she says.

Continuity of care. Dukes reports that surveyors were interested in how a patient progressed through the system, not just the care they received in the ED. "They were looking at the whole puzzle instead of just one piece," she says. Before the survey, Dukes asked the hospital’s infection control director and safety officer to do "walk-throughs" in the ED. "They helped me to identify things that I might have missed," she says.

Dukes included the staff so they could see what "Joint Commission rule breakers" were. Here are some problem areas identified during the walk-through:

  • Emergency anesthesia and thrombolytics box were not locked, and they now are accessed from an automated medication dispenser.
  • Supply rooms had shelving too close to a sprinkler head, so that shelving was removed.
  • Carts in the linen room needed solid bottom shelves, which were installed.

Dukes reports that surveyors "worked up a patient from the inside out." "They selected a patient who was admitted through the ED, looked at the inpatient chart, then the ED chart," she says. "Then they asked about getting a report from EMS, and the floor getting a report from us." Surveyors asked how the sheriff’s department was inserviced on emergency codes at the hospital, Dukes says. "They are looking at the whole picture and everyone involved, including outside entities coming into the ED," she says.

Elimination of redundant documentation. Surveyors wanted to see documentation for procedures done in the ED by other departments, such as respiratory therapy or electrocardiograms, Dukes says. "They wanted to know if it was on a separate form, and we explained that it’s documented on the same ED chart," she says.

This reflects another key concern of surveyors: Elimination of redundant documentation. Dukes gives the example of one ED physician’s request that nurses write a patient’s vital signs and allergies on a separate sheet, although they’re already recorded at triage. "It takes only a minute for them to do, but it’s not efficient," she says.


For more about the new survey process, contact:

Karen Clements, RN, BSN, Emergency Department, Eastern Maine Medical Center, 489 State St., Bangor, ME 04401. Telephone: (207) 973-8010. Fax: (207) 973-7985. E-mail:

April Dukes, RN, Emergency Department, Tift Regional Medical Center, 901 E. 18th St., Tifton, GA 31794. Telephone: (229) 382-7120. E-mail:

Kathryn Perlman, MS, RN, CEN, Emergency Department, Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231-4496. Telephone: (214) 345-6301. Fax: (214) 345-6486. E-mail:

The October 2002 issue of Perspectives includes an in-depth look at the new accreditation process for 2004. The special issue is available free at Joint Commission Resources’ web site at Click on "Past Issues," "2002 Archive," "October 2002, Vol. 22, No. 10 — Free Special Issue on Shared Vision — New Pathways." Printed copies are available for $25 including shipping. To order a paper copy, contact: Joint Commission on Accreditation of Healthcare Organizations, 75 Remittance Drive, Suite 1057, Chicago, IL 60675-1057. Telephone: (800) 346-0085, ext. 558. Fax: (218) 723-9437.E-mail: Questions about the new survey process can be e-mailed to