JCAHO announces upcoming shift to unannounced surveys

New policy requires change in approach to compliance activities

The Joint Commission on Accreditation of Healthcare Organizations’ recent announcement that it will switch to unannounced surveys beginning January 2006 means quality improvement professionals will have to dramatically change the way they think about compliance with standards and ensure that the rest of the organization follows suit. Failure to do so will put your accreditation in jeopardy, says a top Joint Commission official.

And while the switch to unannounced surveys is likely to be seen as a positive move by many, it may come with some drawbacks. The new system will create much more pressure to monitor standards compliance every day, and it may remove some of the incentives that a hospital often employs to motivate employees in preparation for a survey.

Unannounced surveys will be pilot tested in volunteer organizations during 2004 and 2005; then all surveys will be unannounced in 2006. The switch is part of the Joint Commission’s much ballyhooed revamping of the accreditation process known as Shared Visions — New Pathways. That new process, previously announced, already is a radical departure from the current system that health care providers are used to, putting more emphasis on a self-assessment by the provider.

Starting in 2006, organizations will be surveyed anywhere from two to four years after their last surveys. The arrival within that time period will be completely unannounced.

And when surveyors do show up, they will not focus much on documentation and other administrative proof that you’re complying with standards, as they have in the past. Instead, the surveyors will use "tracer methodology" so that they follow the experience of actual patients, using their real experiences to investigate how your organization complied with appropriate standards. Switching to unannounced surveys in 2006 is another step in making the new survey process more consistent with the goal of continuous quality improvement, says Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission.

"The bottom line on Shared Visions — New Pathways is to better embed the accreditation process into the ongoing operational improvement efforts of an organization as opposed to making it an every-three-year event," he tells Hospital Peer Review. "Organizations told us that the icing on that cake would be if the surveys were unannounced. They told us that even though there will no longer be an incentive to ramp up for the survey under the new process, the organization’s tendency might still be to do that, which is counterproductive."

Children’s Memorial Hospital in Chicago, is the first hospital in the country to seek a totally unannounced accreditation review by the Joint Commission. The hospital requested the unannounced full survey, which will take place sometime in 2004, to demonstrate its continuous compliance. During 2004, the Joint Commission expects to initiate pilot testing of the unannounced triennial survey process in up to 100 hospitals that have volunteered to be among the first participants. Four multihospital systems and alliances — Ascension Health, Tenet Healthcare, Veterans Health Administration, and North Shore-Long Island Jewish Health System — have committed to having a number of their hospitals participate in unannounced triennial surveys in 2004 or 2005.

In 2005, JCAHO will continue to conduct voluntary unannounced surveys on a limited basis — opening up the option to all types of accredited organizations, and then transition to a completely unannounced survey program in 2006. The Joint Commission plans to continue to conduct one-day random, unannounced surveys in an annual 5% sample of the health care organizations it accredits through the end of 2005.

Not a gotcha’ game

Making the surveys a surprise is not an attempt at playing "gotcha" with accredited organizations, Massaro says. Rather, the unannounced survey is more consistent with the overall goal of encouraging organizations to comply with Joint Commission standards every day rather than taking a more lax attitude until survey time, he says.

"If people use the new survey process the way it’s set up and work on a more continuous basis, they will have a constant trickle of activity around operations instead of a tidal wave at the end to try to get a good score," he says. "Then it doesn’t matter when the surveyors come, and hopefully, the surveyors will find nothing. That is the goal, and we’ll be very happy if we find nothing."

So what do you need to change in order to be ready for unannounced surveys? "Organizations that are accredited by us won’t have to do anything different with the future process just because surveys will be unannounced," Massaro says, "other than what we already are asking them to do: Stop ramping up for the surveys, and focus on continuous improvement."

Massaro suggests that the change should be welcomed by anyone who has been dismayed at the way some hospitals put on a nice front for the surveyors’ visit and didn’t necessarily put the same effort into standards compliance after the surveyors left. He says currently the survey is the lever for change every three years, but "in the future, it will be validation of change that is ongoing. It will make the survey process more of a genuine quality improvement effort rather than simply an inspection."

While Massaro says the change to unannounced surveys shouldn’t require any different tactics than what providers already are planning for under Shared Visions — New Pathways, he emphasizes that this latest revision should prompt a different way of thinking. If Shared Visions — New Pathways didn’t already change the way you think about Joint Commission compliance, this latest change should, he says.

"You have to divest yourself of your current mindset about accreditation in order to embrace the future model, because all the drivers and incentives are reversed," he says. "For example, now you worry about preparation and getting a bad score. In the future, the process has been designed to eliminate the need for an artificial ramp-up and to incentivize you to use this as a management tool, as an internal asset. Just use the new process as it’s intended, and you will be prepared."

Massaro says it is vital that quality improvement professionals realize that the unannounced surveys are intended as a tool to be used within accredited organizations, not as an attempt at catching more standards deficiencies. The new process is designed to enable continuous compliance that is more consistent with the spirit of the accreditation process, he says. If used correctly, the new system should result in quality improvements and less stress, he says.

"All the rewards in the process are set up for people who use it that way. If the organization chooses to ignore the design of the new process and leave everything to the last minute, and they don’t know when we’re coming, then they’re putting themselves in great unnecessary peril," Massaro says. "On the other hand, if they understand what the new model is all about and how they are rewarded for using it as a continuous model, it is highly likely they will be accredited."

More daily pressure to confirm compliance

Unannounced surveys are a good improvement to the process, at least in concept, says Patrice Spath, RHIT, a consultant in Forest Grove, OR, who watches Joint Commission developments closely.

She agrees with Massaro that unannounced surveys better serve the spirit of accreditation standards and should relieve organizations of the massive effort to prepare for triennial surveys. But even if it’s a good idea in principle, she cautions that the change will bring added pressure to quality improvement professionals.

"The challenge will be making sure that new Joint Commission standards get disseminated throughout the organization in a timely fashion," she says.

"One of the things that happens now is that as you gear up for the survey, you check to be sure everyone is aware of the new standards and get everyone on board. You won’t have a survey date to build your schedule on, so you’ll have to build in to your process your own tickler file to be sure that happens," Spath points out.

You also may need to act more quickly to address new standards and any deficiencies you discover. In the past, you might get word of a new standard or patient safety goal in December, but you knew your next survey was scheduled for July. So you might not start working seriously on that issue until April. You won’t have that luxury three years from now.

"This could amount to more work," Spath says. "You’ll have to be your own policeman, checking all the time for compliance and moving quickly on everything."

Will new focus become a burden?

For those who were never entirely satisfied with the validity of Joint Commission standards, the switch to unannounced surveys will be more of a burden. The new process will force accredited organizations to focus on the standards all the time, not just every three years, which Spath says is fine unless you think the standards are not beneficial.

"There have been questions about validity before, but before we could basically fudge it until three months before the survey and not do a whole lot with the standards you thought were no good," she says. "Here, they’re asking us to be continually ready for something we’re not sure has been proven to make a difference. It’s not a new concern but it becomes an issue when [they’re] asking you to be always ready, continually compliant with these standards when in fact you’re not sure these standards are valid."

But that kind of dissatisfaction is a moot point if you want to keep your accreditation, so Spath advises providers to assess how well their systems can adapt to the new survey process.

Continual readiness will require superb communications processes, for instance. Do you have effective communication channels and feedback processes for when new standards come out? Can you communicate new patient safety goals to the appropriate people and then monitor to see what’s happening with compliance? she asks.

"In the past, we’ve often disseminated them but didn’t check for compliance until close to the Joint Commission survey," she says. "Now you will need continual feedback systems. First, test those systems and make sure they are working OK. If not, start improving them now."

The party’s over?

Spath also points out another drawback that might come with unannounced surveys.

Organizations have long prepared for their triennial surveys by launching a campaign to get all employees involved in getting a good score and trying to create a sense of fun and accomplishment. That motivational tool may be gone in three years.

"Now it’s common to get everyone geared up for the Joint Commission visit, get them excited, then the surveyor would come and you would get a score, and you’d say all of that work was worth it," she says. "You’d say, We got a 92. We did a good job,’ and you’d celebrate everyone’s hard work."

But now it appears the unannounced survey is going to be more of a validation of whether your self-assessment was done accurately and whether you followed up on any problem areas that you identified. There won’t be any numerical scores — just a decision that you are accredited, conditionally accredited, or not accredited.

"I just don’t see a whole of celebration after something like that," Spath says. "It might all be very anticlimactic at that point, and you will have lost one of the strategies for getting everyone on board with compliance.

"How do you celebrate success in that kind of environment?" she asks. "You may need to build some success celebrations into your process because the survey isn’t going to be such a dramatic event any more."

[For more information, contact:

Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000.

Patrice Spath, Brown-Spath & Associates, 2314 19th Ave., Forest Grove, OR 97116. Telephone: (503) 357-9185.]