Surveyors will ask nurses to describe patient care

You won’t know exactly when to expect surveyors

As an ED nurse, you can expect dramatic changes during your next survey from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, as a result of the new "Shared Visions, New Pathways" process and emphasis on continuous readiness.

"This is a very hot topic in our ED, as we are due for survey in January 2004," says Kelly Arashin, RN, CEN, night charge nurse and trauma coordinator for the ED at Hilton Head (SC) Regional Medical Center.

In the past, EDs knew exactly when to expect surveyors, but that’s no longer the case, notes Arashin. "We have been told that Joint Commission will be coming unannounced, so this survey may take place on weekends and nights," she reports. "No one is safe anymore. Everyone must be ready for the surveyors, no matter the shift."

As of this month, surveys will include the new patient tracer methodology. Surveyors will trace a patient throughout the hospital to ensure consistent care is being given, and this change will bring surveyors directly to ED nurses in many cases. Beginning in 2006, all surveys will be unannounced.

"It is certainly a huge improvement over the clean-the-house-for-the-mother-in-law’ mindset that has always surrounded Joint Commission visits," says Elaine C. Keavney, RN, MSN, CEN, ED educator at Good Samaritan Hospital in Puyallup, WA. "In the past, everyone tried to remember exactly what the surveyors might ask, like cramming for a test, and then forgot everything when they walked out of the room."

How to prepare for new surveys

To prepare for the new survey process, do the following:

Give staff mock surveys.

At Good Samaritan’s ED, mock surveys are done in the ED twice monthly to ensure continuous readiness.

"At first, ED nurses were not terribly receptive to the surveyors and the process," Keavney acknowledges. "But after several weeks, they have become accustomed to the process and are receiving it more willingly."

Recent areas of focus have included patient safety, infection control issues, and patient privacy, she says.

At staff meetings at Hilton Head Medical Center’s ED, nurses routinely are asked potential surveyor questions such as, "Where do you keep your protective equipment for hazardous material situations?" "How do you handle narcotic discrepancies?" and "Who do you notify in an event?"

"These are types of questions that we are asking ourselves and co-workers to help us prepare for the real thing," says Arashin.

Ensure that all nurses understand the new patient tracer methodology.

At St. Joseph Hospital in Orange, CA, a mock survey using the tracer methodology revealed a lack of understanding about the new process, says Denise King, RN, MSN, CEN, nurse manager of the ED.

"It quickly became apparent that we definitely have some challenges before us," says King. Frequent mini-mock surveys using the tracer methodology are planned, she adds.

The mock surveyor traced patients from the intensive care and medical/surgical units who were admitted through the ED, and interacted with nurses to discuss the care of the patient while in the ED.

"The challenge here is that they ended up talking with a nurse who did not care for the patient," says King. "So the nurse they interviewed spoke to their daily practice, which was not always in alignment with the daily practice of the nurse who cared for the patient."

Surveyors will look for consistent responses from staff about patient care processes, she stresses. "In the past, we would often try to direct the surveyor to the best’ ED nurse on staff to get their questions answered," says King.

With the new tracer methodology, this process no longer will be possible, as surveyors will be coming to the ED at unscheduled times and will expect consistent answers from any ED staff nurse who happens to be present at that time, she notes.

The mock surveyors questioned ED staff nurses on pain management, calling of report prior to transfer, administration of medication at triage, and documentation for all of these, says King. "It was amazing to me how glaring the variation in practice from one nurse to the next, or from nurse to policy/procedure, can be, especially when a surveyor is inquiring," she says.

During the mock surveys, some of the areas in which practice and policy weren’t consistent included include documentation of pain reassessments, vital signs, and report being given, King reports. For example, nurses medicated a patient three times in the ED for pain but only reassessed pain after two of the three medication administrations, she explains. Also, nurses were 30 minutes late in checking the vital signs of a patient that was supposed to be reassessed every two hours, King says.

The ED uses checkboxes for nurses to indicate when they called report, to whom, and who received the patient, says King. "This area was not completed on the ED record for one of the patients who was admitted, which led to questions about our process for admitting patients and documentation," she adds.

You must closely review your ED’s written policies to be sure they are aligned with the daily practices of the staff, says King. "Have the staff as involved as possible in the writing and review of department policies," she recommends. "This way you can make sure that you are writing a policy that is based on current practice and that the staff are aware of the policy content." 


For more information about preparation for the new Joint Commission survey process, contact:

Kelly Arashin, RN, CEN, Trauma Coordinator, Hilton Head Regional Medical Center, 25 Hospital Center Blvd., Hilton Head Island, SC 29926. Telephone: (843) 689-6122, ext. 8281. E-mail:

Elaine Keavney, RN, MSN, CEN, Emergency Department Education/QI Coordinator, Good Samaritan Hospital, P.O. Box 1247, Puyallup, WA 98371. Telephone: (253) 848-6661, ext. 1051. E-mail:

Denise King, RN, MSN, Nurse Manager, Emergency Department, St. Joseph Hospital, 1100 W. Stewart Drive, Orange, CA 92868. Telephone: (714) 771-8000, ext. 7983. Fax: (714) 477-8527. E-mail: