Avoid disasters during your next JCAHO survey: Quality managers share secrets

Make the new survey process work for you

When you think about the new Joint Commission on Accreditation of Healthcare Organizations’ survey process, do you envision surveyors talking to your organization’s least articulate staff members, selecting patients to trace for whom everything possible has gone wrong, and arriving at units when your most experienced nurses are nowhere in sight?

It’s true that you will have no advance notice or control over where surveyors go or whom they talk to. However, the new survey process will have a positive impact on your role as a quality manager, according to Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting, based in Metamora, MI.

"What I am seeing is that more people in the organization are going to have to take responsibility, and the quality manager’s role will become more of a facilitator," she says.

For example, surveyors now are posing questions during leadership interviews, such as, "We’ve noticed problems with equipment around the building and talked to several staff members about this. What is your plan to do something about this? Are you going to allocate resources for it?"

"The new survey process is putting more of the accountability back on leadership, which is good," Homa-Lowry says. "In the past, it’s often been the quality people will have the answer.’ Now the leaders will, at times, be specifically asked about shortcomings found by the surveyors."

The need for continuous preparedness also will make the quality manager’s role more vital, and, as a result, you can expect to gain more leadership support, Homa-Lowry says.

"In the past, quality people were really important before the survey, and then there was kind of a lull after the survey," she continues. "With the new process, you can’t just ramp up for a few months and let it fall by the wayside."

To avoid problems during your next Joint Commission survey, consider the following tips from recently surveyed quality managers:

• Alert units that the surveyors are headed their way.

Many quality managers acknowledge attempts to give staff even a few minutes advance notice that the surveyors are headed in their direction.

"I think it’s good to give the units a heads-up rather than having surveyors just pop in," says Helena Feather, vice president of compliance and health information at Trident Health System in Charleston, SC. "After all, we are here seeing patients."

When possible, Feather beeped her assistant, who would call the unit or department and let staff know the surveyors were on their way, she notes.

At Augusta (ME) Mental Health Institute, a "runner" shadowed the surveyors as they moved through the organization. "When the surveyor said, OK. We are finished here,’ and started walking to the next unit, the shadow called ahead to alert them," reports Jacquelyn Lewis, RN, MBA, CPHQ, former director of compliance and risk management.

"They may have had a linen cart in the hallway, and little things like that make a big difference with the surveyors’ first impression," she points out.

In addition, you can put staff at ease if the surveyors definitely won’t be paying them a visit on that particular day, says Feather.

"For instance, if you don’t have an orthopedic tracer, then orthopedics is out of the loop for that day at least, so you can rule them out," she explains.

Although there is no specific agenda for patient tracers, you will have a much better idea of which units will be involved during system tracers, so you should use it to your advantage, Feather recommends.

"The agenda does tell you where you are going for system tracers such as infection control or medication management, so you can pull your whole group together," she says.

Have an experienced person review charts with surveyors.

During a one-day extension survey that included patient tracers, it was reassuring to have at least one person on each unit who really knew the charts inside and out, Lewis says.

As a psychiatric hospital, the organization has patient service directors who direct the care on each unit, and they were the ones who reviewed the charts with the surveyors.

"That individual knew how to find everything and was able to walk the surveyor through the chart and explain how what was documented actually reached the patient," she says.

Be ready to recommend patients for tracers.

In some cases, you may have absolutely no say over which patients are traced, but occasionally there may be some leeway. At Augusta Mental Health, surveyors gave Lewis the category for each patient tracer but allowed the organization to select the specific patient.

"They gave us the list of categories at the opening interview, and we had an hour to produce the medical records," she says. "So we had control in that respect. I was afraid they would just ask for a patient list, but that wasn’t the case at all."

Therefore, you should be ready with a list of patients in your top DRGs, Lewis recommends. "Find a patient you did well on for each of those categories so you can have them in mind if asked," she suggests.

It may be possible to point surveyors in the direction of certain patients, but the survey team ultimately will select who it wants to see by diagnosis, length of stay, and admission location, says Darlene Adams, RN, MSN, patient care safety/quality management officer at United Regional Health Care System in Wichita Falls, TX.

"Even when we guided them toward a patient, if the chart was not available on the unit, another patient was selected by the charge nurse or surveyor," she notes.

Identify problem areas in advance.

Use information from your own self-assessment to do this, Homa-Lowry advises. "The more that you have done on the front end, the better off you are," she says.

Your survey application will give you insight as to areas where surveyors will begin to look and prioritize, Homa-Lowry says.

"Unfortunately, in many organizations, that document is not widely shared. It is completed by a group and sent in to Joint Commission," she notes.

Are you compliant across the continuum?

Just because you appear to be compliant in a few areas, that doesn’t necessarily mean you are compliant across the whole continuum, Homa-Lowry warns. "For instance, your pain management may be fine on your surgical floors, but are you doing just as well on your medical units?"

As you identify areas that aren’t in full compliance, you should begin writing plans of action immediately, as you are required to submit them after the survey for areas identified as noncompliant, Homa-Lowry advises.

Also, while your previous performance improvement (PI) reports may have included general recommendations such as "provide education" or "write a new policy and procedure," those will no longer pass muster.

Plans of action are going to have a lot more accountability, since for some standards you’ll have to establish a measure of success that needs to be numerical or quantifiable.

"Many of the things written for the old PI process didn’t really have any teeth to them," she adds. "You now need to really get to the root of the problem."

Be proactive in complying with new standards.

Many changes to the standards will become effective over the coming months, and you must address these well in advance of the "go live" date to avoid problems during surveys. "For example, the new infection control standards are effective 2005.

It would be in an organization’s best interest to be compliant prior to Jan. 1, 2005," Homa-Lowry says.

Ensure staff are knowledgeable about all the patient processes occurring on the unit.

Previously, surveyors would expect various units to know about their specific roles, but they now will want staff to have a more comprehensive understanding of all the processes that occur during a patient’s care in their unit or department, she adds.

"For example, if surveyors see an oxygen tank, they might ask staff why the tank is there, who is responsible for filling it, and who would know how to put it on the patient appropriately," says Homa-Lowry. "By asking these questions, they can get a pretty good idea if staff have a thorough understanding of those processes."

It’s no longer enough for a staff member to tell surveyors that another department is responsible for filling the tank and leave it at that.

New process encourages collaboration

"The bottom line is that there should be knowledge of the entire health care team as to what these processes are. It shouldn’t be an assumption that another department is aware of it," she explains.

For example, surveyors might notice an ice machine that isn’t clean and find out that nurses mistakenly believe that dietary is responsible for cleaning it.

"Then they may go to dietary and find out they actually are not doing it and assume that engineering does it when they repair or do preventative maintenance. Then they might learn that they aren’t doing it, so who is doing it?" says Homa-Lowry.

In that case, you would need to implement a process for making sure this task is completed, she explains.

In addition, staff need to know the process for reporting a problem, as with refrigerator temperatures.

"Sometimes dietary will be independently taking care of that, but it may not get reported back to nursing if there is a problem," notes Homa-Lowry.

Likewise, if surveyors see medications that are not secured, they will ask staff what they do about this.

"The new process is forcing disciplines to work with one another. You can’t just expect a single person or department to be responsible. There needs to be collaboration," she says.

Have a scribe and administrative person accompany surveyors.

During tracers, surveyors may ask to see a policy or procedure or want additional information to refer to later.

"So it’s really important that somebody is going along taking notes. It’s very helpful to have somebody scribing that information, just to make sure those items are ready for the surveyors," Homa-Lowry says.

During the entire survey, Adams was available nearby to help answer questions and get any requested policies, files, charts, or documents.

"We also had the chief medical officer accompany the physician surveyor and the chief nursing officer accompany the nurse surveyor," she points out. "However, they do not want a large group."

Communicate with staff during the survey.

Give staff a heads-up about anything you learn while the survey is still going on, Feather says.

"We had daily briefings on what the surveyors were looking for, what their demeanor was, and the kind of questions they were asking," she reports. "I got this information out by sending out e-mails and sitting down with the direct reports."

Be prepared for long hours

Toward the end of the five-day survey, Feather was able to let staff know that the patient tracers were over. "On Thursday afternoon, the surveyors said they had done all the tracers they needed to do, so we let the staff know we were done," she says.

Come early and stay late during the survey.

The goal is to make sure everything is ready for each morning’s briefing, Adams says.

"We have a report-building system for our census. The first day, we just printed the clinical service groups; but the next day, they wanted the entire census with admission status," she says. "By coming in early, we made these changes without a hitch."

Show monitoring of each National Patient Safety Goal.

Be ready to show evidence of monitoring for each goal for at least the last 12 months, Adams advises. "I had spot monitoring for all the goals, but not 12 months of monitoring for any goal except surgical sites. But they did ask to see it," she says.

Surveyors wanted to see the date of implementation and a 12-month track record for each goal. "All of this information was in the performance improvement book, but they wanted to see evidence of implementation and monitoring of compliance for each goal," Adams explains.

You may need to pull archived policies to show prior compliance, even if you updated your policies to meet the new safety goals. "For example, we used to mark the wrong site in our surgical site policy but changed this to the correct site as of February 2004," says Adams, who needed to pull the old policy to show that the organization had a surgical site marking process implemented previously.

"We also had to pull the minutes from the pharmacy and therapeutics committee to show the evolution of our do-not-use’ abbreviations list," she notes.

Use the special issue resolution session to address issues with surveyors.

This is a 30-minute session that is set aside for surveyors to review results and findings. "Do not expect a long conversation or debate in any session other than the special issue resolution," Adams says.

"If something is not resolved during that session, then you are requested to get more information, such as closed charts or other policies," she continues.

If anything is not clear on your end, this is your chance to discuss it with the survey team. At United Regional, a surveyor had asked about the organization’s blanket orders policy.

"We do not use the term blanket’ so we clarified this with further discussion," says Adams. "We also had a discussion about staff saying repeat back’ instead of read back’ of verbal orders."

After this session, the surveyors have their team meeting/planning session. "That’s when they talked about what they had seen that day and, based on what they did see, determined what they needed to look for the next day," Feather says.

"They would decide whether they needed to go check on something again tomorrow or whether they had looked at a particular issue enough," she adds.

[For more information on the new Joint Commission survey process, contact:

Darlene Adams, RN, MSN, Patient Care Safety/Quality Management Officer, United Regional Health Care System, 1600 10th St., Wichita Falls, TX 76301. Phone: (940) 764-3062. E-mail: dadams@urhcs.org.

Helena Feather, Vice President, Compliance & Health Information, Trident Health System, 9330 Medical Plaza Drive, Charleston, SC 29406. Phone: (843) 797-4299. Fax: (843) 797-4648. E-mail: Helena.Feather@HCAHealthcare.com.

Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, 560 W. Sutton Road, Metamora, MI 48455. Phone: (810) 245-1535. Fax: (810) 245-1545. E-mail: homa lowry@earthlink.net.

Jacquelyn Lewis, RN, MBA, CPHQ. E-mail: jacie@nc.rr.com.]