Try these foolproof tips to be ready for JCAHO

Preparation efforts must change dramatically

If you still are doing last-minute ramp-up preparation for Joint Commission on Accreditation of Healthcare Organizations surveys, you’re going to have big problems with the Shared Visions — New Pathways process, warns Lynne Adams, CPHQ, director of quality at Upper Chesapeake Medical Center in Bel Air, MD.

"Our preparation process is ongoing throughout the year," she says. "Our constant preparation mode paid off with a very positive survey report."

There is no doubt that your preparation efforts will need to change dramatically, adds Jacquelyn Lewis, RN, MBA, CPHQ, former director of compliance and risk management at Augusta (ME) Mental Health Institute.

"With unannounced surveys coming, I just can’t emphasize enough that you have to be ready every day," she says. "We need to get away from the mindset that This is our Joint Commission year.’"

Preparation pays off

Continual preparation paid off with increased staff buy-in at Harford Memorial Hospital in Havre de Grace, MD, according to Jane Gordon, RHIT, director of quality. "The team members don’t feel like we’ve only worked to put on a show for the JCAHO," she explains. "They feel that we truly care about meeting the standards for the well-being of our patients."

Here are preparation tips from the three organizations, which were all surveyed in early 2004:

  • A Joint Commission team meets continually between surveys.

    The team consists of department heads, with each team member responsible for a specific chapter of the standards. Any new standards or revisions are reviewed, and reports are given on any issues that need to be resolved. "We keep an issues tracking list that is reviewed at each meeting, and the item stays on the list until there is resolution," Adams explains.

  • Quarterly mock surveys are done.

    Having mock surveyors make regular appearances on all units allows staff to develop an ease with being interviewed and helps them comprehend the intent of the standards, she says.

    Each Joint Commission team member is assigned a unit, with patients randomly selected for tracing. Tracers were conducted on about 10 patients the month before the survey.

    "It proved to be a great tool for us," Adams notes. "It really helped the staff prepare and be comfortable with the process."

    For example, the mock surveys revealed a lack of knowledge of how to obtain an interpreter for non-English-speaking or deaf patients, Gordon reports. "The mock surveyors spent a lot of time on the units and talked with any team members they came in contact with about how to access this service for our patients," she says.

  • E-mail and paper mail updates are sent to staff on a weekly basis.

    Each communication covers a different hot topic, such as unapproved abbreviations, core measures, read-back of verbal orders, and critical values, Lewis adds.

  • A Joint Commission preparation festival is held.

    Three months before Upper Chesapeake Medical Center was surveyed, a Joint Commission Festival was held, with information booths on specific topics, food, contests, and prizes. The event was held for 24 hours so all staff could attend.

    "It was a lot of work for the Joint Commission team, but it was such a big hit with the staff that it was well worth it," Adams explains. "It was a way to emphasize the new standards and make it fun at the same time."

  • Make sure all staff are comfortable talking with surveyors.

    Be honest: There probably are certain staff members who you would prefer not be questioned at length by surveyors. However, even the poorest communicators can improve dramatically with a little practice, Lewis says.

    She recommends walking around the units and giving staff pop quizzes, such as asking a housekeeper, "What do you do about infection control?"

    "The people you are afraid of putting out front may not present themselves well, but most of the time, it’s only because they get tongue-tied," Lewis adds.

    The goal is to reduce the intimidation factor by getting staff used to answering on-the-spot questions. "Lots of times, staff are afraid of people because of their title or status as a Joint Commission surveyor, and their mind just goes blank," she says.

    If staff are confused by JCAHO-speak, rephrase the question with an emphasis on clinical practice, such as asking, "How do you handle a person who is out of control?" instead of asking about the restraint policy.

    "They often know much more than they realize. These are the things that they deal with every day," Lewis points out.

    Although surveyors generally are using a lot less jargon when interviewing staff, terms such as "core measures" or "verbal read-backs" occasionally may be used. "So it’s still a good idea to get staff used to the terminology," she says. "It also makes them less afraid of the Joint Commission because we speak the same language now."

  • Accept the fact that things won’t be perfect.

    Since surveyors will be arriving unannounced as of 2006, you must accept that everything won’t be flawless. "You will always be in the middle of something; you will always be implementing a new program," Lewis notes.

    Surveyors will understand this and will want to hear why you chose to make certain changes and how far you’ve gotten, she explains.

  • Do chart reviews on a continual basis.

    A full-time chart-review nurse checks for key pieces of documentation on an ongoing basis, which was a big help during the survey, Lewis says.

    At Augusta Mental Health Institute, the required pieces of documentation include a universal assessment within 24 hours, a complete treatment plan within three days, and an assessment of the initial care plan after 10 days.

    "By continually getting all of the pieces in place during the chart reviews, all of that documentation was already there during the tracers," she says. "Having the patient charts polished all the time was invaluable to us."

  • Play games.

    Lewis says that by playing games such as Family Feud and Jeopardy with Joint Commission themes at staff, department, and administrative council meetings, staff learned much more than they expected.

    "We had a stuffed JCAHO bear, and whoever won the contest that week got to have the bear on the unit," she says.

Post "JCAHO jewels."

Lewis posts JCAHO jewels for staff to see throughout the organization.

"I have them plastered all over the hospital, in hallways, on bulletin boards, in staff locker rooms," she adds. For example, one sign says, "Our patients are identified with two forms of identification: A current color photograph posted in the medication room and their birth date."

[For more information on preparing for Joint Commission surveys, contact:

  • Lynne Adams, CPHQ, Director, QHIM, Upper Chesapeake Medical Center, 500 Upper Chesapeake Drive, Bel Air, MD 21014. Phone: (443) 643-2510. E-mail:
  • Jane Gordon, RHIT, Director of Quality, Harford Memorial Hospital, 501 S. Union Ave., Havre de Grace, MD 21078. Phone: (443) 843-5817. Fax: (443) 843-7940. E-mail:
  • Jacquelyn Lewis, RN, MBA, CPHQ. E-mail:]