Unannounced surveys don’t require QI changes
Unannounced surveys don’t require QI changes
But new tools can help with documentation
According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), some random surveys will continue to be performed, even though, as of January 2006, all accreditation surveys are unannounced. "The Joint Commission will continue to conduct unannounced surveys on a 5% random sample of accredited organizations every year through at least 2008," says Mark Forstneger, spokesperson for the Joint Commission.
Does this mean drastic changes for quality managers? Does it require tighter processes, more frequent self-reviews? Not necessarily, states Rita Stockman, RN, MS, director of hospital quality at William Beaumont Hospital in Royal Oak, MI.
"In the past, an organization may have been surveyed [unannounced] even if you had an announced survey in the same year," she notes, "So they have done that all along. I do not believe we have implemented any significant changes [in response to the new policy]."
Beaumont has not had an unannounced survey, Stockman notes. "We know that locally some organizations went into the pilot program," she says. "What they said was that it’s best to keep your communication systems in place — not to make radical changes as much to be sure that people know who their resources are."
Long-standing procedures
Stockman notes a number of long-standing structures and procedures at Beaumont that she believes keep her facility well prepared. "We have had long-standing committees based around each of the (JCAHO) chapters, called chapter teams. "These are multi-disciplinary teams whose role is to communicate with departments and report back to hospital administration, and to let us know what action plans are in progress."
From that point, the JCAHO Education Team (JET) takes over. "For several years the JET has been responsible for drilling down to different standards that staff needs to know at the bedside," Stockman explains, adding that she is one of the members of the team. "These standards are then relayed through the summits and JET documents to the staff."
Over the past few years, "JCAHO Summits" have been held at the hospital. "We have at least one or two in a year," says Stockman. "In January, we announce all new national patient safety goals, as well as any new standards and process changes." The summits are conducted in an auditorium setting, and all hospital leaders are invited.
This year, she says, "We are ensuring that all staff understand the next survey will not be announced and encourage them to use the JCAHO web site for new information, as well as our medical library that includes a link to JCAHO newsletters. Our goal as leaders is to raise the awareness of compliance and survey highlights to the top at the summits — including standards JCAHO states organizations are having a harder time meeting."
In addition, patient safety rounds are conducted annually. "Our team is multi-disciplinary, including clinical staff, clinical engineers, administration, patient safety officers — leaders from different departments," Stockman explains. "We go to the departments on a scheduled basis and review any of their patient and staff safety concerns. So, each department can anticipate one scheduled visit per year."
These rounds have become very popular with the staff, she reports. "People want us to come and see them," says Stockman. "We work with them to address their departmental safety problems or challenges."
Finally, over the last few months "Patient Safety Town Halls" have been held monthly in the auditorium. "They highlight our patient safety processes, what we are doing organizationally to enhance them, and also highlight performance improvement projects that have been brought to our attention," Stockman notes.
Responses in place
When an unannounced survey occurs, says Stockman, Beaumont will definitely be prepared to respond. "When the surveyors arrive, they ideally go to the front door. Our policy says they should be escorted to hospital administration. Then, a designated receiver, such as myself or an administrator, would go with the surveyor," she observes.
There is an internal communication process for alerts, she adds. "It will send a digital page to managers that are on-site," she explains. "They need to be available to support their staff throughout the tracer methodology."
In the past, she notes, surveyors wanted to talk to leaders. "The big change is they want to talk to staff," she notes. "So now managers will want to be sure to be available to support the staff. They have a responsibility to ensure their staff are familiar with patient care standards and patient safety terms, as they will be used throughout the survey process." Those managers in turn are connected to JET through nurses who sit on the team and answer questions continually about terms and expectations.
In order to be adequately prepared, she adds, quality managers cannot operate in a vacuum. "The quality team or department cannot be expected to do it all," she asserts. "It has to be a team effort — departments working together to be continually ready."
And "continual readiness" is the key she emphasizes. "Historically, health care organizations may have functioned by reacting when the surveyors arrived," she says. "With unannounced surveys, organizations that stay continuously ready will be very successful when the surveyor team arrives."
For more information, contact:
Rita Stockman, RN, MS, Director of Hospital Quality, William Beaumont Hospital, Royal Oak, MI. E-mail: [email protected].
According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), some random surveys will continue to be performed, even though, as of January 2006, all accreditation surveys are unannounced.Subscribe Now for Access
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