How to guard against impostor JCAHO surveyors

JCAHO posts reminders about proper procedures

For the second spring in a row, imposter surveyors have sought access to American hospitals. Last year, there were more than half a dozen incidents, and this year there have already been three.

"It seems to be that spring must be impostor season," says Joe Cappiello, vice president of accreditation field operations at JCAHO. "They started at about the same time in March last year; there were about seven to eight until the beginning of summer, then boom — they were gone."

Now, there have been two incidents in Southern California and one in Wisconsin. "The first one was at a facility in the Los Angeles area," Cappiello relates. "A group of five individuals entered a facility and said they were members of the Joint Commission who were there to do a survey. They were correctly challenged, asked to present identification, and they quickly disappeared."

In the second incident, a single impostor presented at a hospital in the LA area — that same week. "I don't know if they were part of the first group or not, but when they arrived, they said they were there to do some preparatory work because the Joint Commission would be doing a survey the next day. When the hospital representative said they had to contact security and check who he was, he, too, vanished," Cappiello relates.

Then, in early April, a well-dressed woman was seen wandering through a Wisconsin medical center. "When she was challenged, she said she was a surveyor, and they asked her for her ID," Cappiello says. "She said, 'Oh, my gosh, I left it in the car,' and she never came back."

A quality issue

Who are these impostors? "If I put on my Tom Clancy hat, I'd think it was preparatory work for terrorists, but I don't think it's that insidious myself," says Cappiello. "Hospitals are rich environments for theft; they have highly expensive narcotics and antibiotics, expensive equipment that is small and getting smaller, and hospitals by design are not secure facilities. The public can easily come and get into hospitals."

If the thieves are not interested in equipment or drugs, he adds, "They could be after data – patient lists, payer data, and so forth."

A quality issue

While such incidents seem on their face to be security problems, Cappiello says they should be the concern of quality managers. "I think, while it is uppermost a security issue, if you look at the standards of the Joint Commission, it is very much in alignment with the standards we have to safeguard the facility and to ensure there's adequate identification of staff," he says. "The other thing we worry most about is infant abductions; drugs and equipment are replaceable, but beyond our general security, we have to control our most precious assets – especially those who are vulnerable to abduction. So, I do think it's a quality problem as well as a security problem."

In fact, he continues, "the whole issue of ensuring safe care through adequate security and identification is a quality issue. Quality managers should work with security to develop a layered security plan."

By the same token, he adds, these incidents should also be thought of in terms of emergency preparedness. "What if you had to lock down the facility?" Cappiello poses. "This all needs to be morphed into one security plan."

JCAHO has put out a notice to all accredited facilities telling them what to do if someone presents at the facility saying they are a Joint Commission employee (The plan also is found on the JCAHO web site:

JCAHO has taken additional steps, in light of the fact that as of January all surveys are now unannounced. "In anticipation of that and in memory of the issues we had last year, this is what we have done," says Cappiello. "At 7 a.m. on the morning the Joint Commission is due to arrive at a facility, on the secure Extranet site we have established with each facility, we will post the fact that we will come that day. There will also be the names of the surveyors, the pictures of surveyors, their biographies, and a letter will be posted signed by my boss saying who is coming, why they are coming, how long they be there, and his phone number. If this is still not enough for you to validate and verify their identities, call us if you are concerned."

He adds that the Joint Commission also has told its surveyors to conduct themselves in the following manner: "When you arrive, go to the front desk or security checkpoint — the first place where you could be challenged — announce yourself, tell them you are from the Joint Commission, and wait patiently while they call administration and someone comes to escort you," Cappiello relates. "Do not wander about."

Reporting an incident

In the most recent JCAHO alert about these incidents, instructions also were given to all facilities about how to respond to an incident. "The last person you want to investigate anything like this is me," says Cappiello. "We want you to let us know that the incident has occurred, so if you want us to send an alert to the field, we will do that. But you need to contact the police and have them come out and file a police report; this way we will have something that can go into our national data base. Your second call is the state's department of homeland security, because last year after the rash of incidents, we managed to talk with the FBI, with homeland security, and for the first time a database was developed to log and catalog and track suspicious activities in and around health care facilities. Now, someone who is knowledgeable could look at trends or patterns to better understand what is going on."

For more information, contact: Joe Cappiello, vice president of accreditation field operations, Joint Commission on the Accreditation of Healthcare Organizations. Phone: (630) 792-5757.