Accreditation Field Report

JCAHO 'backup' system goes to top during survey

Surveyors shared best practices

When Joint Commission surveyors walked into Sacred Heart Hospital in Allentown, PA, the hospital's "backup" system went into effect. For everyone not present, a backup person went into action who knew where all the relevant documents were.

"In most cases, the primary person did happen to be there, but when that wasn't the case, it worked seamlessly," reports Diane Horvath, the hospital's JCAHO coordinator. Even the hospital's CEO, who was absent for the entire survey due to illness, was backed up by other members of the executive management team and spoke with the surveyors by phone. "The surveyors recognized that the CEO doesn't do all the work," she says. "They spoke on the phone about some of their findings and what their thoughts were, and that was fine."

Similarly, surveyors didn't necessarily expect staff to drop everything when they walked into a room. "They were accommodating and understood that they walk in cold and people have things to do," says Horvath. "If they needed to go to a floor and a staff person was involved in something, they would rearrange the schedule to accommodate that."

Best practices shared

Throughout the survey, surveyors shared best practices from other organizations, including a reappointment profile for credentialing of medical staff. "It included all the different pieces of medical staff quality — utilization, infection, pharmacy — all the things you want to evaluate. They told us we might want to consider implementing that because they feel it meets the intent of the standard," says Horvath. "We are looking at methods to easily collect all of the data."

Overall, staff were happy with the new survey process, reports Horvath. "It was hard for me as the JCAHO coordinator, but staff liked being continuously ready and not having to prepare for only six weeks prior to survey," she says. "They enjoyed the tracer methodology."

The surveyors made sure to trace patients from all of the organization's priority focus areas. "They were able to follow patients who were transferred when they visited the unit in the next level of care, such as from the intensive care unit to the medical/surgical unit," says Horvath. "The surveyors wanted to speak with staff, and our staff did a great job telling the surveyors what they do every day."

Surveyors assessed compliance with the Joint Commission's Universal Protocol while interviewing staff about surgical charts, looked for unapproved abbreviations everywhere, and looked at timeliness of critical test results and methods of ensuring accurate patient identification. "The data-use tracer was an interesting interview," says Horvath. "They focused a lot on patient flow in that interview and asked about quality data." Surveyors didn't focus on data presentation at all, she adds. "They saw how we collect and present data at our monthly performance improvement committee meetings and did not have any recommendations," says Horvath.

During the medication management tracer, surveyors asked a multidisciplinary group to pick a medication. "The group picked insulin, and they followed it from the time it is purchased until it is given to the patient," says Horvath.

During the environment-of-care interview, surveyors looked at disaster and emergency preparedness. "They asked what we would do in the case of a 9-11 type disaster," says Horvath. "They were interested in how we are involved in our local community. We have a great regional group that meets regularly, so they were happy with that."

One major change for the organization was that home care, hospice, and hospital were all surveyed together.

"This was a change for us, and we saw how one survey can affect the others," she says. Quality professionals took full advantage of the opportunity to challenge any findings that they didn't believe were representative of the care provided. "You do have ten days to clarify any things they found that were not right. It's a lot of work, but it's well worth it," says Horvath.

Use of unapproved abbreviations was one finding that was challenged successfully. "In the survey process if they find two uses of unapproved abbreviations, that's an RFI. But you can go back and do a clarification based on the methods they give you. If you can prove it, you can get it overturned," says Horvath.

JCAHO requires that you use a specific formula for doing the reports, using its sampling criteria and records no more than 30 days before survey occurred. Quality professionals at Sacred Heart spent a week auditing 70 charts and immediately sent the results to JCAHO. "We got a response in about a week, and the RFI was overturned," says Horvath. "You can't challenge them onsite, but surveyors were very clear that we had the right to clarify any of their findings after they leave."

[For more information, contact:

Diane M. Horvath, Director, Medical Staff Services, Sacred Heart Hospital, 421 Chew St, Allentown, PA 18102. Telephone: 610-776-4839. Fax: 610-606-4405. E-mail:]