JCAHO, unannounced: Just-surveyed organizations share compliance tips

The first three hours can make or break your next survey

When a group of surveyors from the Joint Commission on Accreditation of Healthcare Organizations walked into St. Jude Medical Center in Fullerton, CA, in January 2006, staff were ready and waiting for them — even though the survey was unannounced and completely unexpected.

"We didn’t really expect them until March, since that was when our last survey occurred. It was just a wishful hunch, although we heard they were running early," says Pat Wardell, vice president of quality management and patient safety officer.

So how did staff know the surveyors were coming that January morning? They checked the Joint Commission’s Extranet site religiously every morning beginning January 1, 2006 — as any organization can. At 7 a.m. Eastern Standard Time, the site will tell you if today is the day — information that’s posted along with surveyor biographies. For organizations in other time zones, the window of advance warning is up to four hours, since surveyors arrive at 8:00 a.m.

"Our house supervisor checked the site at 5 a.m. every morning, and called me at 5:01 to tell me that JCAHO was coming that morning at 8:00 a.m.," says Wardell. "Staff were here by about 6:30 a.m. It did give us some leeway, and kept us from being panicky when they walked in the door."

Quality managers at La Cross, WI-based Franciscan Skemp — Mayo Healthcare System—also one of the first organizations surveyed in 2006 — found out that JCAHO was coming by checking the Extranet site as well. "That gave us about 20 minutes time to start the communication rolling, which was a definite plus," says Kristine Von Ruden, RN, the organization’s quality improvement specialist and Joint Commission coordinator.

The time was used wisely — to gather documentation, notify staff, arrange for catering and refreshments, and make arrangements for the conference room to be available for surveyors’ use. "It was like running a code. We delegated tasks and knew what had to be done," says Von Ruden.

The extra few minutes of lead time allowed the organization to project a calm, confident demeanor, as opposed to being caught completely by surprise, Von Ruden explains. "Their first impression is a lasting impression," she says. "The majority of us were able to be there when the surveyors arrived, and our CEO was able to greet them in our hospital lobby."

When it’s your time to greet surveyors, will you be blindsided, scrambling to collect a current patient census, wondering why key leaders haven’t responded to pages?

Or will you have spent the past hour waiting for the surveyors to arrive, ready to greet them with a firm handshake and all the required documentation in hand, with all hospital staff already on full alert?

The answer really depends on whether you’ve done some simple advance preparation, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Healthcare in Charlotte, NC.

"The first three hours will make or break your survey," says Swain. "That’s the time when you can project an image of organization and show surveyors you’ve got it together. That is where you want to put your practice time."

If you are frantically getting paperwork together when surveyors arrive, it puts you in the defensive mode and you’ll be playing "catch up" during the rest of the survey, she warns.

JCAHO’s unannounced surveys began on January 1, 2006, so no more advance warning will be given to any accredited organization. Hospital Peer Review interviewed several of the first organizations to be surveyed under the new 2006 process. Approximately 1,500 hospitals will undergo an unannounced survey this year.

"We were not expecting our survey for another five months. This was truly unannounced and a complete — 7:45 am — surprise," says Mike Zwirko, CHE, vice president of Holyoke (MA) Medical Center. "We were the first hospital in Massachusetts to have the unannounced survey."

The very first thing staff did was ask the surveyors for identification, says Zwirko. "With reports of imposter JCAHO surveyors last year, we were trained to ask this of anyone who identifies themselves as an inspector or surveyor," he says.

Next, the surveyors were given a conference room as a "home base" to work from, and a beeper system was used to notify senior staff and managers — the same process used by the organization to alert staff during disasters.

"That was very effective, and the surveyors were impressed how quickly the hospital staff were notified," says Zwirko. "We also provided a runner to get them the needed policies and documentation."

Although harrowing at times, quality professionals say the Joint Commission’s new survey process is a definite improvement. "Since we were one of the first organizations surveyed with the new unannounced process, we had to get rid of some preconceived ideas," says Wardell. "But if you are trying to look at really improving patient care, this method makes the most sense."

Here are proven strategies from just-surveyed organizations:

Use the JCAHO’s Survey Guide as a resource.

The guide is an essential tool in being prepared for the new unannounced process, and there are some important changes for 2006, says Swain. "The concepts are the same, but it is somewhat different as JCAHO is trying to address the unannounced process," says Swain. "If you don’t follow this guide and practice it, you won’t have the right people in the right places."

Pay close attention to the section that addresses the surveyor arrival and preliminary planning session, says Swain. "In that session, the surveyors and the hospital come to a consensus on the general survey logistics,’" says Swain. "All of the surveyors will be there together with the possible exception of a life safety code surveyor, who may not show up until the following day."

Have alternatives identified for staff notification.

Everybody needs to know who his or her "backup person" is, says Swain. For instance, Presbyterian does its orientation presentation in a slide program because it prompts staff to address all the required topics. "But what if the speaker you’ve planned to present it isn’t there that day? You’ve got to have somebody else who has practiced it and is familiar with it," says Swain.

On survey day you have to go with whoever is there, so cross-training is essential, says Swain. "Even in my office, if I am gone, then others can step in. If my administrative assistant who opens the command center is gone, the CEO’s assistant steps in," she says.

At Mayo Healthcare, a three-tiered response plan was used with key persons identified for various roles. "We had a plan A, B, and C — so if one person wasn’t able to be there, we would just go to the next one on the list," says Von Ruden. "We generally knew if someone wasn’t in that day or had conflicts that could not be re-arranged."

Be strategic about JCAHO’s location.

Chose a room for surveyors that is not right next to your staging area — where you do your planning, dispatching, chart review, personnel file review, and policy acquisitions. "Don’t make them too close together," recommends Swain. "While you are previewing personnel files, medical records, and strategizing, you do not want the surveyors bumping into your commotion. What is presented to the surveyors, is cool, calm, and without surprises!"

Before the survey, Wardell met with the catering service and the CEO’s administrative assistant to come up with a plan for the room the surveyors would work from. "That was very helpful because once we found out JCAHO was coming, we could immediately set about getting the rooms open that we had discussed so there was a place for them to set up right away," she says.

In addition, a room staffed with two people was arranged in advance, so whatever surveyors requested could be provided quickly. "Those were the things that kept us from having a confusing first morning," says Wardell.

However, the organization’s staging area was located on the floor below the surveyor’s area. "So it was close enough, but far enough away. Once they requested a particular policy or procedure during patient tracers, we could quickly get it to them," she says.

Mayo Health decided to have JCAHO surveyors set up in a conference room adjacent to the administrative offices, says Von Ruden. "Staff would sit outside and just wait to hear what they wanted to look at. We gave them a list of survey contacts so if they needed something and one of us wasn’t around, they knew who to call."

Have a schedule available just in case.

When one of the surveyors at Presbyterian realized she didn’t have a schedule in hand, Swain quickly produced one that she’d used during mock surveys. "I had gotten it off the Extranet, and we used it to practice with. They were very thankful that they had a guide for where they were going," says Swain.

Find trouble spots in the schedule.

If staff members are responsible for more than one area, individuals might end up required to be in two places at the same time — something you’ll need to negotiate in advance. "In smaller hospitals, staff may wear two or three hats. By going over the schedule with the surveyors, you can identify those problem spots," says Swain.

On the last day of the survey, be sure to factor in enough time for all the "clean up" and reporting the surveyors have to do. "Be clear as to which hospital staff will attend the surveyor’s exit briefing," says Swain. "They really like to have very few people attend and will not want to discuss any of the standards cited."

Despite the surveyors’ request for few people, Presbyterian had the entire senior operations group present, which comprised about 15 people, she adds.

Give surveyors the right materials.

If surveyors ask to see a personnel file during a patient tracer, you need someone in the staging area to look it over to make sure it’s complete, says Swain. "You need good communication to keep material rolling. You don’t want to give them material that you haven’t had a chance to preview," she says. "Is it the right thing, based on their request? Is it complete and concise and what you want them to see?"

If your policies are not accessible electronically, there’s a risk of someone going to a binder and pulling out an outdated policy, says Swain. "Most likely, a master book has a revised policy, and that is the one you should hand them," she says. "You want to control from the staging area who is handing them what."

To be sure that information is always updated, some organizations have developed Survey Readiness Boxes, similar to "disaster boxes" used during mass casualty incidents, says Darlene Christiansen, RN, LNHA, MBA, JCAHO’s executive director for accreditation and certification operations. The boxes typically include the most current patient census, a phone tree for notification, policies and procedures that you know surveyors will ask for, and pertinent data, kept updated all the time.

At St. Jude, blue binders with the required information each have designated "owners" responsible for keeping them updated at all times. "If a "Code Jude" is called, that individual takes the books to the staging area," says Wardell. "Everyone has a buddy’ who knows where the books are kept. That way, if the owner’ is not there, we still know where to find it."

Drill your process of staff notification.

At St. Jude, telephone operators were asked to put all managers and supervisors into a "Code Jude" group, so a single page could alert everyone at once. The group page was accomplished in about eight minutes during the survey, reports Wardell.

The notification of staff should be tested during your disaster drills, to identify people with outdated numbers or beepers without text paging capability, says Swain.

"Every single time we have practiced, we have been able to update our emergency notification list," she says. "When you do the exercise, either the individual is notified or not. And if not, then they have to fix that. People will say, I didn’t get paged.’ This testing policy puts the responsibility on staff to fix it now."

During a practice session, it was discovered that one hospital didn’t have its text paging system rolled out yet, so Swain contacted the corporate IT department, which had it up and running just a few hours later.

If this hadn’t been resolved before the organization’s unannounced survey, every single person would have had to be contacted individually. "It would have taken an hour just to do the notification," says Swain.

If you don’t have text paging, two-way phones or walkie-talkies also can be used — or in a pinch, even faxes. One hospital printed out a stack of pages that stated "I am at _______." "When surveyors left an area, the nurse could stick a page in the fax saying I’m at OB,’ so that way we at least knew where they were," says Swain. "They also began to fax pages saying, We are going to…’ to let us know where they were going next."

The key is to be creative and use any method that works, says Swain. "Think of any way you can to keep the communication open and then practice that. It’s an extra edge."

Take immediate action when surveyors spot a problem.

"It isn’t until the mid-point of the survey that the surveyors compile the list of things they are really going for broke on," says Swain. "That is when you are doing damage control."

Your goal is to try to ensure that after surveyors find a problem, they won’t find that problem anywhere else in the organization. If surveyors note a cigarette butt in the stairwell, put out an all-points-bulletin to alert staff to make sure they don’t find another one anywhere. "Or let’s say you get a recommendation for a patient plan of care. You need to get examples of patients inhouse who have good plans of care. You want to show surveyors that their one finding was just a fluke."

[For more information, contact:

Paula Swain, MSN, CPHQ, FNAHQ, Director of Clinical and Regulatory Review, Presbyterian Healthcare, 200 Hawthorne Lane, Charlotte, NC 28204. Telephone: (704) 384-8856. E-mail: psswain@novanthealth.org.]

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: vonruden.kristine@mayo.edu.

Pat Wardell, Vice President, Quality Management and Patient Safety Officer St. Jude Medical Center, 101 E. Valencia Mesa Dr., Fullerton, CA 92835. Telephone: (714) 992-3000, ext. 3763. E-mail: pat.wardell@stjoe.org.

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