JCAHO gets praise for new survey style

Surprise visits start this year

Two years into using the "tracer methodology" of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to survey accredited facilities, the agency is receiving "a constant stream" of positive feedback, says Joe Cappiello, BSN, MA, vice president, field operations, for the Oakbrook Terrace, IL-based organization.

"They're saying, ‘Finally, you have got it right. This is where the rubber meets the road,'" he adds. "It's about the delivery of patient care."

In addition to marking the exposure of the final third of JCAHO facilities to the new methodology, Cappiello notes, 2006 also heralds the beginning of the agency's unannounced visits.

"Only those scheduled to be surveyed in 2006 are going to be exposed to the unannounced process [this year]," he says. "If you're due, it's going to be done in 2006, but if the anniversary of your last visit is December, we might do you in February."

Hospitals are allowed to provide JCAHO with a number of "blackout dates," which the agency will honor, Cappiello says. "If you know that May 4-6, you're going to have an emergency preparedness drill, or that on Aug. 9, you will have a medical staff retreat, those are not good times for us to be there."

But he points out that "care goes on 24-7, and the CEO, director of nursing, and medical director are not always there, so what does it matter if we arrive when some of the leadership is not present?"

Then and now

Before 2004, JCAHO surveyors developed an agenda for each hospital visit, with blocks of time set aside to be in certain areas, Cappiello explains. "We might be in unit 9G from 9 a.m. to 10 a.m., and then go to the emergency department from 10 to 11. Included were the obvious places — the ED, the operating room, any site where anesthesia is administered — and then a sampling of the general units of the facility."

Hospital leaders were alerted to be on hand for several formal sessions, and there was much questioning about policies and procedures, he says. Staff, meanwhile, did things like write "the top 10 questions surveyors will ask" on the back of their hospital badges, Cappiello notes.

Now the blocks of time are allocated for tracers, whereby "between 15 and 18 patient charts, at an average-size facility" are pulled, and the course of those patients' care is followed through the hospital, he says.

Before going to a facility, the agency develops a profile of the facility that suggests where to start the tracer, Cappiello notes. "This is publicly accessible information based on codes [the hospital] submits to the Centers for Medicare & Medicaid Services, and based on its accreditation history, sentinel events, complaints, and various sources we have available. So we are being directed by the data toward certain units or certain services."

At the beginning of the survey, he continues, surveyors ask for patients who are in-house or recently discharged from those units or services, and then randomly select some charts. "We actually follow the path of those patients."

If the data suggest a look at the cardiology service, for example, surveyors might come across the chart of a Mrs. Lopez, who came to the hospital via the ED after a 911 call to which paramedics responded, Cappiello says. "Maybe she got a number of diagnostic tests — a scan, radiology, cardiac catheterization — and winds up where she is today, in the cardiology unit."

Surveyors might go to the point of entry, the ED, and, if possible, meet with the staff that took care of Lopez a few days before, Cappiello adds. If they're not available, surveyors will go to other ED employees — "not management, but those directly administering care."

"We'll say, ‘Tell me how you would manage a person who is 50-plus, overweight, on a number of medications, brought in by ambulance, and complaining of chest pains,'" he continues. "The nurse might respond, ‘We have a cardiac protocol, etc.,' and that begins to lead us down a path of questioning."

While talking with the nurse who took care of the patient, surveyors might take note of the fact that Lopez spoke only rudimentary English, and ask the nurse how she communicated with her, Cappiello says. "We're not trying to make a judgment on clinical delivery of care, but to understand whether the staff is competent in their ability to care for the patient and all of her special needs.

"Are they prepared, are they adequately trained? Do they have the necessary knowledge and experience, and are they caring in a way that ensures a good outcome and protects her dignity?"

Surveyors will follow the patient's course to the bed she is currently in, Cappiello says, continuing on to radiology, for example, and asking staff about their care of Lopez, or someone like her: "What training did they receive? How do they care for the equipment?"

As patients travel through a medical center, he points out, "they literally come into every part of our standards. So we don't have to go down a checklist. All we have to do is follow that course and talk with the staff and management that have surrounded the patients in their travels."

Asking about access

Going back to the example of Mrs. Lopez, Cappiello says, "it may very well be that her admission was done in the ED by access staff who will have to communicate with her, understand what her source of pay is, etc."

While in the ED discussing her care, he adds, surveyors may notice an access employee admitting a person in a nearby cubicle, and decide to follow up on those registration issues, and talk to frontline staff about how they do their job.

"The beauty of this is, there are no trick questions," Cappiello says. "If we engage someone from access, we will ask them how they do their job, and how well they were prepared to do the job."