When you go through an unannounced survey, will you sink or soar?

Joint Commission process receives high marks from those who prepare

Since the Joint Commission on Accreditation of Healthcare Organizations launched its unannounced surveys in January, more than 1,370 organizations have gone through the new process. For hospitals that had been surveyed at press time, the average number of requirements for improvement (RFIs) increased to 7.4 in 2006 compared with 5.8 in 2005, and the average RFIs for ambulatory care facilities increased to 6.7, compared to 5.8 in 2005.

While smaller surgery centers (those doing fewer than 1,500 cases per year) receive a five-day notice to ensure the center will be in operation during the survey, most outpatient surgery programs don't know the Joint Commission surveyors are coming until that information, along with surveyor biographies and photos, is posted on the agency's extranet web site at 7 a.m. Eastern Time. (Go to www.JointCommission.org, and go to the "Jayco Login" section. After logging in, click on the "notification of scheduled events" link.)

To ensure your program receives top marks and avoids RFIs, consider these suggestions from outpatient surgery programs that have been through the unannounced survey process this year:

• Have a system to communicate that surveyors are on-site, and use a last-minute checklist.

Staff at Baylor All Saints Medical Center at Fort Worth (TX) paged managers the morning of Jan. 16 to let them know the surveyors were coming that day, says Beverly Joanne Kennemur, RN, manager of same-day surgery. Other facilities use telephone trees, and one facility put everyone on alert by announcing, "We welcome the Joint Commission surveyors" on its public announcement system.

Advance notice does help, she advises. Baylor All Saints had developed a last-minute checklist, which was posted in the same-day surgery department, Kennemur says. (See checklist.) "The staff knew to look at the checklist, to go over it, and to make sure we had followed all those guidelines," she says. In 20 minutes or fewer, all the steps were completed, she recalls.

• Have staff educated about how to handle surveyors' arrival.

The issue of identifying surveyors has taken on additional importance in light of recent reports of more impostors attempting to gain access to hospitals in California and Wisconsin by posing as Joint Commission surveyors.

Ensure that several people in your program know how to confirm surveyors' identification, says Michael Kulczycki, MBA, executive director of ambulatory care accreditation. Staff should ask surveyors for identification. Their identification can be confirmed by signing in on the agency's extranet web site or by contacting the Joint Commission by phone or fax. (Staff should look up the numbers themselves to ensure they are correct, rather than obtain them from the surveyors.) In some cases, surveyors have had to show staff how to sign on at the web site and check the identification, he says. The front desk receptionist should have that information available and should know to take the surveyors to a conference room so they can review materials and create an agenda while the organization's leaders determine which of them are on site to help during the survey, Kulczycki says.

"If the administrator is not there, keep in mind that the survey is not designed around the administrator or Joint Commission coordinator," he says. "Sixty percent of the total survey time for a typical ambulatory surgery center, which is two days [total], is spent talking to frontline staff." In smaller surgery centers that have six to 12 staff people, the surveyor is likely to talk to every single staff person, Kulczycki adds.

• Be ready to provide key documents.

The biggest issue for programs going through unannounced surveys is the amount of time it takes managers and staff to get organized the morning of the surveyors' arrival, says Kulczycki. There is a list of documents that are important to keep on hand to provide to surveyors right away, he says. (See list.)

"Except for the daily or weekly scheduled procedures, everything is pretty static," Kulczycki says. Ensure these documents are updated with information such as new services when they are added, he adds.

• Assist surveyors by assigning someone to accompany them on tracers.

While it's not required or expected that a staff person accompany surveyors on patient tracers, it is helpful for the agency and the surveyed program, Kulczycki says. For example, the staff person can ensure that the surveyor is talking to staff who aren't immediately involved in patient care, so that process isn't interrupted, he says. Another benefit is that the staff person can help keep the surveyor on time after the surveyor has stated the amount of time that he or she wants to allot to the tracer process. Another benefit is that if the surveyor requests policies or procedures, the staff person can arrange to have that information pulled so it is available by the time the tracer is completed, he says.

The person accompanying the surveyors should carry a memo pad and note not only what the surveyors want, but also what they find and what they say, suggests Mark Mayo, executive director of the Illinois Freestanding Surgery Center Association in St. Charles. "This will help you identify and fix a problem, maybe before the surveyors leave, and will help you with a plan of correction," he says.

• Practice tracers during peak times.

When programs conduct mock tracers in preparation for the unannounced survey, their natural tendency is to schedule it for a slow day, Kulczycki says. "What is the likelihood that a surveyor will show up on a slow day?" he points out. "You want to test your processes when you're running at your peak, not during a slow time."

Use a wide range of staff to conduct the mock tracers, Kulczycki suggests. For example, your front office staff can examine procedures in the postoperative area that they're less familiar with, and your clinical staff can look at admitting procedures, he says. "This will help with testing your compliance with your requirements and looking for process errors where you can improve," Kulczycki says.

The same-day surgery department at Baylor All Saints prepared by watching a tracer video and doing mock tracers with staff, Kennemur says. "If they don't know an answer, we tell them to refer to their supervisor or manager," she says. At the actual survey, one patient was traced through the department to radiology, Kennemur says. "They were watching how they identified the patient, how they received reports," she says. "They wanted to know how we knew the doctor was on staff and what their privileges were."

At Holyoke (MA) Medical Center, fewer than seven mock tracers were done as preparation for the survey, says Brenda Loguidice, RN, MBA, CNOR, manager of perioperative services. Does she recommend that number for other facilities? "I'd say to do as many as they could, to tell you the truth," Loguidice says.


For more information on the unannounced surveys, contact:

  • Beverly Joanne Kennemur, RN, Manager, Same-Day Surgery, Baylor All Saints Medical Center at Fort Worth, 1400 Eighth Ave., Fort Worth, TX 76104. Phone: (817) 922-2068.
  • Brenda Loguidice, RN, MBA, CNOR, Manager, Perioperative Services, Holyoke Medical Center, 575 Beech St., Holyoke, MA 01040. Phone: (413) 534-2500. E-mail: Brenda_Loguidice@holyokehealth.com.

For resources on the unannounced surveys, including a video, go to www.jcaho.org and click on "unannounced surveys" on the left side of the page.