ED Accreditation Update: Wary of unannounced surveys? Try these tips

Many ED managers are unsure of how to prepare for unannounced surveys from the Joint Commission of Accreditation of Healthcare Organizations, which began for all facilities on Jan. 1.

Here are insights from those who have had firsthand experience with the process:

• You may be surprised by the timing of the survey.

Even though the Department of Veterans Affairs (VA) Long Beach (CA) Healthcare System had volunteered to pilot test the unannounced survey system this year, the managers were surprised by the timing of the visit.

Not up to the usual level of preparedness

The hospital had been surveyed in August 2001, and the managers thought they would be visited closer to the month they were last surveyed. On a scale of 1-10 of survey preparedness, with 8 being their typical level of preparedness, they were at a 2 or 3, says Duane Schmuck, nurse manager at VA Long Beach.

• Have a backup manager available.

Providers often are concerned that department leaders may not be available when the surveyors show up for an unannounced survey, says Linda Murphy-Knoll, MN, vice president of accreditation service operations at the Joint Commission.

"Since we’ve pushed the process to the staff level, it’s most important that staff be available to surveyors," she says.

The Joint Commission encourages EDs to have a backup person available in case the top leadership isn’t available, Murphy-Knoll explains.

• You may not know what your surveyors are doing.

At VA Long Beach, surveyors had access to electronic medical records, so they were able to obtain information from the computer without asking for it specifically, says Jeff Miller, MD, FACEP, medical director for Team Health, the physician group in the ED.

"It was difficult to ascertain some of what they were doing because of this," he says.

Also, just because the surveyors aren’t in the ED doesn’t mean that patients aren’t being traced, Schmuck says. "I reminded people down here: Anything they do down here, just because surveyors aren’t here, doesn’t mean patients aren’t being traced."

Schmuck, who was overseeing the intensive care unit while that manager was on vacation, says, "I made a couple of trips to the ED to compliment them on their documentation, which was reviewed from afar in the ICU, patient floor, and even nursing home patients were traced to the ED."

While there was only one actual visit of a surveyor to the ED, "we were reviewed on multiple occasions," Schmuck says.

• Surveyors will ask staff members questions related to their jobs.

At Norton Suburban Hospital in Louisville, KY, and other facilities, surveyors ask staff about what they do for the patient.

"When you give caregivers the opportunity to talk about what they do on a daily basis, they’re very comfortable talking about them, instead of referring back to policy," says Heather Cote, RN, BSN, MBA, chief nursing officer and vice president for patient care at Norton Suburban.

At VA Long Beach, surveyors asked clerks about issues such as the Health Insurance Portability and Accountability Act that are pertinent to their jobs, Schmuck says.

"It didn’t seem like they had any hidden agenda," he adds. "There were no trick questions. They were friendly to staff."

Miller had advised the physicians and nurse practitioner to answer any questions simply and honestly without adding superfluous information. "They seemed to do well," he adds.

• Surveyors will look at all areas, including security.

During the VA Long Beach survey, a surveyor noticed a police substation located outside of the ED by the triage area. The surveyor interviewed the police for 15 minutes and asked to see the camera system, Schmuck says. The surveyor was concerned that there had not been a police presence when he arrived that morning or the previous day, he says.

"We have a sign-in book, but he felt the area should be manned the whole time, and visitors should have a visitor’s pass," Schmuck says.

• Ensure your files are in order.

To prepare for unannounced surveys, ensure your yearly competencies are up to date, Schmuck advises. "Make sure the entire staff is not just competent with procedures, but also with changing hospital policies," he says. "If everybody is current on all those things, they can answer any question thrown at them."

Have a designated ED education liaison to make sure this is done, Schmuck suggests.

Make sure everyone is familiar with the usual ED quality assurance policies in areas such as X-rays, labs, and EKGs, etc., Miller says. Make sure your personnel files are in order and up to date and that no one is delinquent on any certification or credentialing issue, he adds.

Although the concept of unannounced surveys sounds disconcerting, Murphy-Knoll has some words of comfort: "We’re not giving out scores, and everyone has 90 days to respond to anything we find on site. The final decision doesn’t come out until after that."


For unannounced surveys, contact:

• Jeff Miller, MD, FACEP, Medical Director, Team Health, Department of Veterans Affairs (VA) Long Beach Healthcare System, Emergency Department, Long Beach, CA. E-mail: DrJeffMiller46@aol.com.

Duane Schmuck, Nurse Manager, VA Long Beach Healthcare System, 5901 E. Seventh St., Long Beach, CA 90822. Phone (562) 826-5665. Fax: (562) 826-8159. E-mail: duane.schmuck@med.va.gov.