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This February, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, released its annual list of random unannounced survey (RUS) topics. Under JCAHO’s RUS policy, 5% of organizations accredited under the ambulatory care, behavioral health care, home care, hospital, and long-term care programs will receive an RUS. Any organization can be selected for an RUS between nine and 30 months after its full survey and will not receive prior notice that a surveyor is coming. This year’s topics are:
With only 5% of all organizations receiving such surveys, is there any way to determine whether yours is at greater risk for an RUS? "Not that I know of," says Kay Beauregard, RN, MSA, administrative director and hospital safety officer at William Beaumont Hospital in Royal Oak, MI. And therein lies the rub. Since there’s no way to tell if you’re likely to be visited, "You should be ready any time," she advises. Beauregard strongly believes this is a message quality managers need to hear, she says. "I think we should almost belabor this point. You would think it’s intuitive, but many hospitals just ramp up prior to their survey."
Beauregard’s staff have been using what they call a readiness cycle for the past five years. "Basically, we have teams that meet on a regular basis to assess standards compliance," she notes. Each team is structured across departments, based on the set of standards it is assigned. "Since there are 14 sets of JCAHO standards, there are 14 teams," Beauregard explains. "For example, environment of care is one standard," she says. These teams are referred to as chapter teams.
Overseeing the team structure is the Joint Com-mission education team, or JET, which is a corporate committee that includes representatives from these departments:
The chapter team is responsible for the content of the standards — for knowing the standards, interpreting the standards, and remaining current on the JCAHO activity related to the standards. "They openly discuss the standards and interpret them within their teams, review new standards, create and maintain a work plan, [and] identify any deficiencies and actions to resolve," Beauregard says. "They report to the steering committee on a regular basis," she adds.
Operating on a parallel path is an education group that reviews information from the chapter teams and assesses the need for hospitalwide or group education. The readiness cycle, when charted out, might look something like this:
A constant state of readiness is even more critical because JCAHO is not the only organization that conducts random surveys, Beauregard notes. "The Centers for Medicare & Medicaid Services [CMS] also has the potential to do validation surveys, to ascertain if you are in compliance with its conditions of participation," she points out. "If you are JCAHO-accredited, CMS recognizes that, but just to validate that the Joint Commission is surveying properly, [it will] come in and do unannounced surveys of [its] own. That’s all the more reason for you to stay ready."
Even if you are not selected for a random survey, you should pay careful attention to the RUS topics, Beauregard advises. "You might draw from their inclusion that these could be hot topics for future regularly scheduled surveys," she suggests. "They are clearly seen as problem-prone areas, since they are included in the random surveys, so they are probably seen as hot topics by JCAHO."
For more information, contact: Kay Beauregard, RN, MSA, Administrative Director and Hospital Safety Officer, William Beaumont Hospital, 3601 W. 13 Mile Road, Royal Oak, MI 48073. Telephone: (248) 551-5000. E-mail: firstname.lastname@example.org.