Accreditation Field Report

Key aspects of a recent Joint Commission survey

Surveyors focused on staff knowledge, patient care

Throughout a recent Joint Commission survey at Paradise Valley Hospital in National City, CA, surveyors zeroed in on two key areas: staff knowledge and patient care, reports Catherine M. Fay, RN, director of performance improvement.

"The surveyors provided a great deal of education and consultation information. The staff felt a sense of achievement when they finished their turn with the surveyor," she says. "For management, the difficulty was in not knowing where the surveyors were going."

Here are key aspects of Paradise Valley’s survey:

Tracers were selected according to diagnosis and/or processes.

In general, the tracer methodology process was very close to what Fay had expected.

"Our educational efforts with staff stressed that any patient could be selected for a tracer. However, we did anticipate that the focus might be the patients with diagnoses we had selected for core measure data collection, such as cardiology and pulmonary," she adds.

In total, there were about 12 tracers, including home care and behavioral health, with two in the core measure categories and the others in priority focus areas.

Once the initial patient was selected, linkages to other processes were driven by diagnostic procedures, treatments, or questions that the surveyors had, Fay notes. For example, when surveyors learned that a patient being traced had a blood transfusion, the tracer moved from the patient to every one of the processes involved with the transfusion, beginning with the order.

Fay says that she was surprised at how carefully the linked processes were traced.

"The process was very detailed in its continuity and thoroughness," she says.

Once a patient had been selected for a tracer, the process linkages could go anywhere.

On several occasions, the surveyor even changed destinations midroute, Fay explains. On the way to the intensive care unit for one patient tracer, the surveyor switched gears and decided to start a different tracer on another patient in a step-down unit. 

During another tracer, a surveyor was on the way to the cardiac catheterization lab and learned that they were in the middle of a procedure, so he decided to head to the same-day surgery unit to review the patient’s chart before returning to the lab.

The system tracers were not what had been anticipated.

System tracers were data use, infection control, medication management, competency, environment of care (EOC), and leadership, and were not what Fay had anticipated.

About 18 individuals were identified to participate in each system tracer, because she had anticipated the surveyors would want input from all of the service areas for how medication management was implemented across the organization, for example.

But in actuality, the surveyors discussed the process for each function, not necessarily how it applied to each service, Fay explains.

For example, the surveyor used a medication order in a patient’s chart and had the group verbally walk through the process from the written order for the medication to documentation of the effects, including questions relating to the National Patient Safety Goals.

In retrospect, it probably would have been better to have a smaller number of staff participate, specifically individuals who were more directly involved in the system tracer process, Fay says.

"The EOC system tracer was the document review for life-safety standards, and we did downsize the group when we learned that document review was to be the focus," she adds.

Staff liked the new process.

During survey preparation, department directors were reminded that the surveyors were expecting to speak with staff and not managers.

"We had heard from other facilities that some of the surveyors had requested that the managers not answer questions directed to the staff," says Fay. "In the medication management system tracer, the physician surveyor did request that vice presidents not answer any questions."

Initially, staff were nervous about being questioned directly but later conveyed appreciation for being able to talk directly with the surveyors, Fay says.

"Conversely, the management team was in the unusual position of not talking with the surveyors and were prepared not to answer questions unless no one else could, or the questions fell to their area of expertise, such as operational or budgetary issues," she notes.

Documentation review was limited.

This was limited to specific processes being traced, with the most detailed document review related to the EOC life safety standards, Fay explains.

"For the most part, personnel files were selected from staff to whom surveyors had spoken. Medical staff files were randomly selected from patients’ medical records," she says.

Communication among caregivers was an area identified for improvement.

The focus was that documentation in the patient’s medical record should provide sufficient information to prevent error and miscommunication, Fay points out.

"When a patient is transferred from one area to another, the providers receiving the patient must have enough specific information to assume the care of the patient," she adds.

[For more information about the organization’s JCAHO survey, contact:

Catherine M. Fay, RN, Director of Performance Improvement, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Phone: (619) 470-4263. Fax: (619) 470-4162. E-mail:]