Are you prepared for an unannounced visit from the Joint Commission?

New survey method calls for constant readiness

Are you ever ready? That is the question of the day as the Joint Commission on Accreditation of Healthcare Organizations moves to unannounced surveys.

As of January, Joint Commission surveyors no longer notify hospitals when they will arrive; their survey approach has changed as well. They'll spend less time reviewing documentation. Instead, as they trace the care of individual patients, they will observe employees as they work and ask them questions about issues from sharps safety to infection control.

"There's really no script that organizations can study for," says Nancy Kupka, DNSc, MPH, RN, project director in the division of standards and survey methods.

Hospitals shouldn't just focus on the standards, she says. "Walk through your organization and say, 'Where do we have good practice and where does our practice need to be improved?' Then come back and look at the standards. If you're doing all the common-sense things we've all been taught and following the infection control guidelines put out by the Centers for Disease Control and Prevention and professional societies, you should be fine."

The Joint Commission process should fit into your quality improvement efforts, she says. "We're looking to see how organizations are improving. Every organization has problems. We're not trying to catch you. We're trying to help you do a better job."

Keeping HCWs on their toes

Of course, hospitals still stress over Joint Commission surveys. But preparing for a survey will no longer seem like cramming for an exam. The new survey process requires a new way of thinking.

Sue Sebazco, RN, CIC, immediate past president of the Association for Professionals in Infection Control and Epidemiology and an infection control/employee health director in Arlington, TX, applauds the Joint Commission's approach. The surveyors will focus on the patient experience — and patient safety, ultimately, is at the core, she notes.

Still, constant preparedness can be a challenge. "It's just keeping us on our toes all the time," she says. "One of the biggest challenges is making sure that the staff will be prepared on an ongoing basis and that they will be comfortable with the information they might be asked."

Sebazco makes sure employee immunizations and TB skin tests and risk assessments are up to date. Her hospital expects a survey during 2006, so she is making a special effort to make sure employees are comfortable with employee health and infection control questions they may be asked.

A team focuses on survey preparedness and periodically walks through units, posing questions such as: Where do you report an injury? What do you do if you have a needlestick?

If the employee answers correctly, they receive candy and their name is placed in a raffle for small gifts, such as a free meal at the hospital cafeteria.

Questions could be posed to any employee, from those in environmental services to nursing. "Everybody's awareness is going to be at a heightened level at all times," says Sebazco.

The Joint Commission has placed priority on hand hygiene, including it in its National Patient Safety Goals. Sebazco's hospital posted signs in patient rooms asking patients to remind their caregivers to wash their hands. Patients also receive a brochure when they check in, asking them to participate in their safe care and suggesting they remind practitioners about washing their hands.

"We put hand hygiene [products] in our hallways rather than just in our patient rooms," says Sebazco. "We have definitely seen an increase in compliance since we've done that."

Observation boosts compliance

At the University of California at Irvine Medical Center, a special committee meets twice a month to review Joint Commission standards and the hospital's performance. "The intent of the unannounced survey is to instill a sense of a constant state of readiness. Our organization has certainly taken that to heart," says Linda L. Dickey, RN, MPH, CIC, manager of infection control and epidemiology.

For example, the hospital has focused on improving hand hygiene with new products and convenient placement of hand gels. Staff also have developed an observational tool, which light-duty workers or unit volunteers periodically use to monitor compliance. They mark boxes on the form as they watch whether health care workers perform hand hygiene before direct contact with a patient or performing a procedure. (See a copy of the observational tool.)

Each unit has at least 20 observations a month, and the feedback encourages improvements in compliance. That quality improvement effort is what the Joint Commission wants to see, Dickey says. "Every organization in this country is trying to figure out how to accurately monitor hand hygiene compliance."

Meanwhile, infection control and employee health staff also review applicable guidelines to make sure their practices are up to date, Dickey says. For example, they reviewed the response to employee exposures to communicable diseases and made changes in their influenza immunization program to make it easier for employees to receive the vaccine.

These activities will be ongoing, reports Dickey. "It's just like cleaning your house," she says. "It's so much easier if you keep up with it all along rather than doing it once or twice a year. That makes for a better-run organization and a safer organization for patients."


When will JCAHO arrive for unannounced surveys?

  • Between 2006 and 2008, the unannounced survey will occur in the year that the organization is due for survey.
  • Subsequent unannounced surveys will occur 18 to 39 months after the organization's first unannounced survey.
  • Hospitals may identify up to 10 "blackout" dates when an unannounced survey should be avoided.
  • Joint Commission surveyors still may come during that blackout period if the reason given is such that a survey can be reasonably accomplished.