New Joint Commission mandate: Be ever ready for surveyors

Surveyors may ask employees about safety

This year, surveyors from the Joint Commission on Accreditation of Healthcare Organizations may not ask you much about employee health. But they may question employees — or observe their safety practices — to find out how well your hospital protects them from hazards.

In 2004, surveys become more patient-centered, focusing more on the patient’s experience and less on paperwork and policy. The revised standards eliminate EC1.1.1, which was specifically directed at employee health, and substitute a more general standard, EC1.10, which states, "The organization manages safety risks."

That change actually may strengthen the position of employee health, says Geoff Kelafant, MD, MSPH, FACOEM, medical director for occupational health and employee health at McLeod Regional Medical Center in Florence, SC.

"What it really is saying is that the organization has to have an integrated safety plan," says Kelafant, who was involved in the development of the prior employee health standard as a consultant to the Joint Commission. "Staff safety and patient safety and environmental safety are all equally important."

The Joint Commission promised streamlined standards as part of its new Shared Visions — New Pathways program. The elimination of the employee health standard was a part of that, says Britt Berek, CCE, MBA, associate director for standards interpretation.

The new wording in no way lessens the emphasis on employee health and safety, he says. "Whether there’s greater emphasis . . . depends on what surveyors see" as they track a patient’s experience, he says. For example, they may ask an employee administering chemotherapy about personal protective equipment (PPE) or a nurse where a lift is kept and how it is used. "They should know their job rather than just memorizing our standard," Berek says.

This new process is less scripted and less focused on review of policies and procedures, he says.

The rhythm of the survey process also has changed. Instead of spending several months preparing for a scheduled visit, hospitals will conduct a self-assessment, which the Joint Commission surveyors will use to streamline their visit. However, hospitals will have the option to undergo a short midcycle survey by JCAHO rather than conducting a self-assessment.

Beginning in 2006, the survey will be unannounced, which means hospitals must be ready to face scrutiny at any time. Some hospitals will pilot test the unannounced survey process in 2004 and 2005. Additionally, 5% of all accredited organizations will be randomly selected for unannounced surveys each year beginning in 2004.

The Joint Commission will no longer publish scores, and it has changed its accreditation categories.

"They’re going to be looking at all the key areas," says Mary Ann Codeglia, RN, CIC, administrative director of clinical process improvement at San Ramon (CA) Regional Medical Center. "Obviously, safety and quality are a key focus for them."

Employee safety has been tied to patient safety, and patient safety is the centerpiece of the Joint Commission’s seven National Patient Safety Goals. "The fact that they are going to unannounced surveys puts hospitals on notice to make sure they comply with all the standards all the time," she says.

Preparing for this new style of survey will be far different than for the previous surveys, which placed more emphasis on interviews and document review. Hospital Employee Health asked employee health experts to share their advice on how to get ready, and stay ready, for the Joint Commission:

Review your safety-related training.

Now you have a new reason to make sure your employees are getting the message from your health and safety training. For example, they need to know not just where to find the lift equipment and how to use it but when to use it. If a surveyor randomly asks a nurse or nursing aide about the ergonomic equipment, will they get an explanation — or blank stares?

"This is going to be a challenge to make sure everybody is trained and understands what they’re doing," Kelafant says. "It’s probably going to be an awareness-building exercise for a lot of organizations to find out how poorly their employees retain information. That’s going to be the weak link. All it takes is for the employee to fail to put on PPE or not activate a safety device, and then [surveyors] are going to start asking questions," he adds.

You may want to add some additional health and safety items to your annual competency exams. Some hospitals may need to revamp their training to make it more effective, Kelafant points out.

Pitt County Memorial Hospital in Greenville, NC, has an employee health nurse who responds to all blood exposures. She is able to track and follow up on problems with safety devices or work practices, says Pat Dalton, RN, COHN-S, occupational health administrator. The blood exposure nurse contacts managers after needlesticks, counsels employees, and can provide additional training.

Make your written policies user-friendly.

Suppose a surveyor asks an employee about a certain policy and procedure — and he or she doesn’t know the answer. "The staff member is allowed to say, I don’t remember, but I know where to look it up,’" Kelafant adds.

Your job will be to ensure that the policies and procedures are accessible and easy to understand. You may need to put some additional policies in writing. Also keep in mind the range of both clinical and nonclinical employees.

"The surveyors could potentially go to a lot of different places, some of which they may not have gone to in the past," Berek says. For example, a nurse surveyor may visit the lab or pharmacy as a part of tracking the patient experience and then may ask safety-related questions, he explains.

Conduct walk-throughs to observe compliance with safe practices.

Employee health may take a more prominent role in regular environment-of-care rounds or walk-throughs. By visiting different departments in weekly or biweekly rounds, employee health professionals can check on safety knowledge and compliance. In a see-through sharps container, they may be able to estimate how often employees are activating safety devices. They may ask office workers about their comfort and adjust their workstations for better ergonomics.

Anticipating the new style JCAHO survey, San Ramon Regional Medical Center is adding new questions for rank-and-file employees as part of the checklist for environment-of-care rounds. (For a sample checklist, go to:

"[We want to] ensure that they actually know what they should be doing in certain circumstances," says Cindy Fine, RN, MSM, CIC, director of infection control and employee health. "Where do you find the PPE? What would you do if you got a needlestick? Do you know where the lift equipment is and how to use it?"

On his environment-of-care rounds, Kelafant takes along a camera. In his written reports, he highlights safety issues that need to be addressed, before an injury occurs.

Keep paperwork updated continually.

You can’t cram for an unannounced survey. Would your paperwork be up to date if the Joint Commission showed up tomorrow?

"Every hospital does the best they can to stay survey ready," Codeglia says. "We do the best we can, but we all know people are crunching a couple months before their scheduled survey to make sure everything’s in line."

For example, you’ll need to make sure you keep your TB skin testing documentation continually up to date. As surveyors track the experience of a particular patient, they may pull the employee health records of individuals who provided clinical care — rather than asking employee health to provide some sample files, Dalton notes. They may then look for hepatitis B vaccination or other issues.

"They’re going to want the hospitals to prove that we have provided a safe working environment, that we have employees who follow the [U.S. Occupational Safety and Health Administration} guidelines for vaccinations," Codeglia explains.

"You’ll have to keep on your toes all the time," Dalton says.