ED Accreditation Update: Continuous compliance: Starting in 2006, your ED must be prepared for unannounced accreditation surveys

If your emergency department (ED) is in the process of preparing for your hospital’s triennial accreditation survey this year, or will have one in 2004 or 2005, it will be the last time you have to deal with the stressful ramp-up.

The announced regular accreditation survey will be gone in about two years. In its place, starting in 2006, will be surveys that are completely unannounced, the Joint Commission on Accreditation of Healthcare Organizations says.

In hopes that reaccreditation surveys will become snapshots of ongoing compliance rather than ramped-up "shows," the Joint Commission says that following a pilot test of unannounced surveys in 2004 and 2005, all surveys will be unannounced. Regular accreditation surveys will continue to be conducted every three years, but organizations won’t know when surveyors will show up.

And while the idea might seem unlikely, the idea to implement a process of all surveys being unannounced came from the organizations, according to one Joint Commission officer. Accredited organizations promoted the idea during the past year as they became acquainted with Shared Visions — New Pathways, the new accreditation process that will be implemented in January 2004.

"We didn’t include unannounced surveys [as a component of the new accreditation process]," states Russell P. Massaro, MD, FACEP, executive vice president of accreditation operations for the Joint Commission. "But as we presented it and received feedback, it seemed as though unannounced surveys would be the way to go, as well, because it makes [accredited organizations] shift to the final outcome, which is to improve patient care continually through the process."

Under the current survey process, all organizations undergo announced triennial surveys, and 5% each year are chosen to receive random, unannounced surveys. When the new survey process takes effect in 2006, random, unannounced surveys will be discontinued. Reaction has been positive to the announcement, sources say.

"This is the way it should have been all the time," says Leslie Furlow, PhD, RN, C-FNP, president of AchieveMentors, a management consulting firm in Tolar, TX. "It’s a way to make sure [hospitals] do the right things for the right reasons, all the time."

Furlow states that for the ED, as well as other departments, "The best way to be ready, of course, is to stay ready."

Unannounced surveys give accurate picture

Children’s Memorial Hospital in Chicago is one of the first hospitals to volunteer to participate in the pilot test next year. Cathleen Shanahan, RN, BSN, TNS, MS, director of the ED, Transport Team, EMS, and Trauma, says she is glad to see the change.

"There are a lot of times that hospitals put on a show [for scheduled surveys], and after the survey team leaves, things are not maintained at the same level," Shanahan says. "This way, we will be providing an accurate and consistent picture."

An incentive to staying ready for an unannounced survey, Shanahan says, is that it’s easier to maintain standards than to regain control of them if they are allowed to slip. "Once you lose control of one of the standards, it tends to spiral downward," she says.

New scoring makes survey less scary

While much of the response to the announcement has been positive, the Joint Commission knows it has its work cut out for it to re-educate organizations that unannounced surveys need not be "scary," Massaro says.

"Under the current [accreditation] process, no one wanted unannounced surveys, because they could mean lower scores," he says.

By eliminating the scoring penalties that can result from shortcomings found on unannounced surveys under the current process, and instead, substituting a grace period for those shortfalls to be corrected before the decision on accreditation is posted, organizations can see the unannounced surveys as they are intended: as accurate reflections of what a hospital is doing right and what needs to be improved, Massaro says. When unannounced surveys take effect, rather than receiving numerical scores, organizations will be rated as accredited, conditionally accredited, or not accredited.

"By eliminating the publication of scores, and giving people 45 days to make corrections before the decision [on accreditation or reaccreditation] is made public, where’s the downside to the unannounced survey anymore?" he asks. Accreditation that’s achieved in an unannounced survey process also increases the credibility of the accredited status in the eyes of the public and health care payers, Massaro says.

Under the new process, once a hospital is accredited, it may earn optional "merit badges" that recognize specific care certifications in areas including cardiac care or status as a magnet facility for nursing. The merit badges are optional, and an organization must first earn accredited status before requesting special distinction in one of the specific care certification areas.


For more information on the Joint Commission’s shift to unannounced surveys, contact:

  • Russell P. Massaro, MD, FACEP, Executive Vice President, Accreditation Operations, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000. Fax: (630) 792-5005. E-mail: rmassaro@JCAHO.org.
  • Cathleen Shanahan, RN, BSN, TNS, MS, Director, Emergency Department, Transport Team, Emergency Medical Services, and Trauma, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614.
  • Leslie Furlow, PhD, RN, C-FNP, President, AchieveMentors Inc., P.O. Box 185, 200 N. Oak Lane, Tolar, TX 76476. Phone: (254) 834-3333; toll-free: (877) 331-4321. Fax: (254) 835-4993. E-mail leslie@achievementors.com. Web: www.achievementors.com.