On-site JCAHO surveys offer lessons to others

The Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) switch to conducting all types of on-site accreditation surveys and certification reviews on an unannounced basis is causing risk managers and other administrators to rethink some key strategies. This major policy change requires a shift in the way risk managers help get their organizations ready for a Joint Commission survey, say those who have already been through unannounced inspections.

Instead of spending months feverishly getting everything in tip top shape for the scheduled survey, now you have to be sure everything is right all the time, they say.

In announcing the new plan, Joint Commission president Dennis S. O'Leary, MD, said the new process "should create an impetus for each organization to be in compliance with 100% of the standards 100% of the time. Making on-site evaluations less predictable and more focused on potential performance issues is intended to satisfy both public demand for greater organization accountability and organization demand for greater value in undergoing these outside evaluations."

During 2004 and 2005, the Joint Commission pilot-tested the unannounced survey process in various types of volunteer organizations. The responses from the organizations involved in the pilot were positive, the Joint Commission reports, but also identified the need to provide short (five-day) notice of surveys to certain types of organizations. These include prison facilities, Department of Defense installations, organizations that do not operate on a regular five-day-per-week basis, and very small entities (such as some physician offices) where an on-site survey might totally disrupt daily operations.

From 2006 through 2008, the unannounced survey will occur in the year in which the organization is due for its next survey. Subsequent unannounced surveys will occur during an interval of 18-39 months after the organization's previous unannounced survey. The timing of subsequent on-site evaluations will be determined by criteria derived from Joint Commission monitoring of organization performance data.

For-cause unannounced surveys will continue to be conducted whenever warranted. The Joint Commission will continue to conduct one-day random unannounced surveys in an annual 5% sample of organizations that have not yet undergone full unannounced surveys. Over time, these unannounced surveys will be replaced by random unannounced on-site evaluations of steps that accredited organizations have taken to remediate previous citations.

Unannounced surveys do have the intended effect of keeping you on your toes, says Gloria Swanbon, director of quality and risk management for Merrimack Valley Hospital in Haverhill, MA. The hospital was surveyed in late January. She says the hospital was ready because the prospect of an unannounced survey changed the culture and how the organization ensures compliance with Joint Commission standards.

"You have to always be prepared. You can't wait until next year to put something new in place," she says. "Whenever JCAHO releases a new requirement, you have to implement it right away. Before, we felt like we had that two- or three-year leeway."

The new approach is actually easier, Swanbon says. Instead of a furious rush to prepare when the survey date approached, the hospital implements changes steadily, she says. Joint Commission surveyors also have changed the way they look you over and what they want to see, Swanbon notes.

"Instead of spending the day talking with administrators and sitting through the presentations that we put so much work into, they're out on the floor talking to staff," she says. The staff interviews come as part of the patient tracer process in which patient records are traced through the different departments of the hospital in which they were treated. "That's a big turnaround," Swanbon says. "They want to talk to staff in many departments and ask them directly about JCAHO compliance."

The surveyors were especially interested in anything related to patient safety, Swanbon says. That emphasis included medication administration, medication reconciliation, fall prevention, and many aspects of handoff communication. After talking with staff, the surveyors requested copies of certain hospital policies and the staff education records for some of the individuals they spoke with.

Swanbon says the experience was not as daunting as she had feared, and the same report comes from Ann Staroszczyk, CPHQ, director of quality management at Aurora Sinai Medical Center in Milwaukee. The Joint Commission surveyed the hospital in early February. Like Swanbon, she says one of the biggest differences was the focus on the staff instead of hospital administrators.

"JCAHO is really focusing a lot more on what matters instead of being satisfied that you could put together a sharp presentation by senior administrators," she says. "They're out there talking to people on the front line and actually watching them work, observing patient care. It's a very different focus, and it means you have to be in compliance all the time."