Avoid anxiety: Start early for accreditation survey

Use preparation as self-evaluation

Survey. Audit. Review. It doesn’t matter which word is used — any time someone from another organization comes to your agency to evaluate how you do your job, it is nerve-wracking.

The best defense against accreditation survey jitters is good early preparation, says Karen Cober, RN, MSN, administrator of Medical Center Home Care & Hospice in Johnson City, TN.

In addition to the paperwork preparation of the New York City-based Community Health Accreditation Plan (CHAP) self-study guide, Cober’s agency holds review sessions with staff members prior to the CHAP visit. "We ask questions about our strategic plan, our policies, and other issues that the CHAP site visitor may ask to give everyone a chance to answer or hear the answer in a safe, group setting," she explains. "We also videotape the meetings so employees who are unable to attend can review the information as well."

Preparing staff for home visits with surveyors also is important, suggests Diane H. Flynn, BSN, MBA, a St. Louis-based consultant for Joint Com-mission Resources in Oakbrook Terrace, IL.

"Conduct mock surveys as you accompany staff members on site visits," she says. "Ask them questions that a surveyor might ask about infection control, emergency policies, or other aspects of their jobs. Be sure your staff members know that they can admit that they don’t know and have to ask a supervisor," Flynn explains. "It is better to admit that they have to ask, rather than having them make something up."

Home health and hospice agencies seek accreditation by either CHAP or the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), for a variety of reasons.

In addition to serving as a seal of approval to reassure community members that the organization sets high goals for quality and meets those goals, the accreditation also may eliminate the need for other audits or surveys to achieve "deemed status" for Medicare participation. Although some hospital-affiliated home health agencies believe that JCAHO accreditation is necessary if the hospital is JCAHO-accredited, that is not necessarily true, Cober says.

"Because we have multiple hospitals and multiple home health agencies as well as a durable medical equipment (DME) company and pharmacy, we had to prepare for and undergo nine separate JCAHO surveys," Cober explains. Not only was this expensive in terms of accreditation fees, but also in terms of staff time, she adds.

Because JCAHO and CHAP have had an agreement since 1996, which states that JCAHO will recognize CHAP accreditation as a substitute for JCAHO-focused surveys for community programs such as home health, hospice, and DME, Cober approached CHAP about reviewing the home-care division as one entity instead of individual agencies. "We were able to streamline the accreditation process by preparing as one organization with one survey time," she adds.

By choosing to obtain "deemed status" as part of the CHAP survey, Doris Mosocco, RN, CHCE, director of quality management for Riverside Hospital Home Care Division in Newport News, VA, was able to eliminate state surveys for her home health agency. "We still undergo the state survey for our hospice since our state regulations require it, but the CHAP survey meets our state requirements for home health," she explains.

Mosocco points out that these requirements differ from state to state, so a home health manager needs to check his or her state regulations.

One part of your preparation for a JCAHO survey should be to pay attention to your surveyor’s background, suggests Greg Solecki, vice president of Henry Ford Home Health Care in Detroit. The surveyor for his November 2001 survey was an infusion nurse who had a special interest in and knowledge of infusion and infection control. While she reviewed policies and practices in relation to JCAHO standards, she did emphasize her two areas of expertise, he says.

"We were surprised by one infection surveillance recommendation," Solecki says. "We thought we had covered every JCAHO characteristic in our pre-survey review. We had never heard of a requirement to check and document the TB incidence rates in the counties we service and establish our staff TB testing frequency accordingly," he explains. "Frankly, we thought it was a significant enough achievement that everyone had [his or her] TB tests on time and that the documentation was in the personnel records."

Solecki admits that the surveyor’s approach was constructive, and his agency easily was able to accomplish the task and will be able to update it regularly. 

"We try to make our site visits educational," says Terri Ayer, RN, MS, CNAA, interim president and chief executive officer for CHAP. "We also realize that organizations are going to be anxious because we are disruptive just by being there," she says. "We aren’t looking for perfect; we are looking for organizations that are working hard to do things right. We like to see organizations that recognize their own problems and are working toward solutions."

[For more information on accreditation surveys, contact:

  • Terri Ayer, RN, MS, CNAA, Interim President/ Chief Executive Officer, Community Health Accreditation Project (CHAP), 61 Broadway, New York, NY 10006. Telephone: (800) 656-9656 or (212) 480-8828. Fax: (212) 812-0394. Web site: www.chapinc.org.
  • Karen Cober, RN, MSN, Administrator, Medical Center Home Care & Hospice, 1807 W. Market St., Johnson City, TN 37604. Telephone: (423) 431-6146.
  • Diane H. Flynn, BSN, MBA, Consultant, Joint Commission Resources, 322 Longview Blvd., St. Louis, MO 63122. E-mail: dflynn@jcaho.org.
  • Doris Mosocco, RN, CHCE, Director of Quality Management, Riverside Hospital Home Care Division, 11833 Canon Blvd., Newport News, VA 23606. Tele-phone: (757) 594-2656. E-mail: doris.mosocco@rivhs.com.
  • Greg Solecki, Vice President, Henry Ford Home Health Care, One Ford Place, 4C, Detroit, MI 48202. Telephone: (313) 874-6500. E-mail: gsoleck1@hfhs.org.]