Is your facility prepared for surveyor imposters?

Contact security and police if incident occurs

A group of well-dressed people walk into the main entrance of a southern California hospital and announce they're going to do a walk-through before a JCAHO survey. In another California facility, a professional-looking man comes to the lobby and explains that he is with JCAHO and needs access to several clinics. When a woman is found wandering the hallways of a Wisconsin hospital, she says she's doing work in preparation for a JCAHO survey.

All these individuals were imposters, and all fled as soon as they were challenged by staff. Would they have gained access to your facility?

A year after individuals impersonating JCAHO surveyors tried to enter hospitals in Boston, California, Detroit, and elsewhere, a rash of similar incidents has occurred.

Although in these cases the imposters all claimed to be from JCAHO, other individuals may present themselves as employees of pharmaceutical companies, contractors, or other agencies.

"I don't think anybody knows how many imposters present themselves at medical centers. We just hear about the ones claiming to be with JCAHO, but I'm sure there are others," says Joseph Cappiello, JCAHO's vice president of accreditation field operations. "Our medical centers are not closed facilities. You can walk in, and, by and large, they don't have someone at every door 24 hours a day, seven days a week."

As for a motive, Cappiello says his gut feeling is that theft is a more likely possibility than terrorism. Possibilities include narcotics, antibiotics, portable medical equipment, or personal identification data of patients.

"We did contact the FBI and the Department of Homeland Security just to make sure that someone at a national level was collecting data to see if there were any patterns to this," he says. "It's certainly not the JCAHO's desire or expertise to get into the investigation of these incidents."

For this reason, JCAHO has instructed organizations reporting incidents to contact local law enforcement and ensure there is a police report and contact their state office of homeland security so that the incident is registered in a federal database.

The positive side is that most organizations have taken steps to increase their awareness and level of security, says Cappiello. "I believe they have taken these messages to heart, based on the number of calls I have received after each of our alerts," he adds. "They have reviewed their internal policies and established new parameters for identification of all persons presenting at their medical centers."

On JCAHO's part, surveyor badges have been modified with embedded holograms to make them more difficult to copy, and pictures and biographies of surveyors are posted on the Extranet site by 7 a.m. on the morning of an organization's survey.

"We have instructed all our field surveyors to make sure badges are displayed, report to the front office or security desk, and patiently wait for the verification and validation to take place," says Cappiello.

If there is ever a question as to the validation of a surveyor's identity, staff should err on the side of caution and call the hospital's own internal security, he underscores. "None of us want untrained staff trying to be heroic," he says.

At La Cross, WI-based Franciscan Skemp-Mayo Healthcare System, an unannounced surveyor policy states that when any type of surveyors present, they must show their credentials and will have an escort. In addition to JCAHO, other surveyors may come unannounced, such as state surveyors, federal surveyors completing a validation survey, or surveyors from the Occupational Safety and Health Administration or the Office of Inspector General, notes Kristine Von Ruden, RN, the organization's quality improvement specialist and Joint Commission coordinator.

"We posted little cheat cards in our receptionist, nursing, and information areas that outlined the key steps to take in the event of a surveyor arriving," says Von Ruden. "We also did an education session with managers so they could take it to their staff."

When JCAHO presented for an unannounced survey, the surveyor's identities were verified via the Jayco Extranet site. "Our director of quality pulled their info up, and surveyors waited in a conference room that was used as their headquarters," she says.

At Holyoke (MA) Medical Center, staff are trained to ask for identification from any individuals who present themselves as surveyors, says Mike Zwirko, CHE, vice president. "In addition, all sales people must report to purchasing to register and get special badges. Sales people are known to just walk into pharmacy or surgery selling their wares," says Zwirko. "This also applies to equipment service or repair technicians from outside companies."

[For more information, contact:

Kristine Von Ruden, RN, Quality Improvement Specialist/JCAHO Coordinator, Franciscan Skemp Healthcare-Mayo Healthcare System, 700 West Avenue South, La Crosse, WI 54601. Telephone: (608) 791-3889. E-mail:

Mike Zwirko, CHE, Vice President, Holyoke Medical Center, 575 Beech Street, Holyoke, MA 01040. Telephone: (413) 534-2554. E-mail:]