Unannounced JCAHO surveys mean more planning, not less

Change may lead some to abandon JCAHO, expert says

The upcoming switch to unannounced surveys by the Joint Commission on Accreditation of Healthcare Organizations will require a dramatic change in how you prepare for the visit, experts say, with even more attention to the tried-and-true methods that have worked for years, plus new strategies to ensure your organization truly is ready to be inspected at any moment. Brace yourself for more work and a good dose of frustration, they say.

Some hospitals may find the new system so onerous that they will abandon the Joint Commission altogether and rely on other types of accreditation, says Susan Mellott, PhD, RN, CPHQ, FNAHQ, a consultant in Houston.

"Hospitals are going to hate it, absolutely hate it, because they can’t predict anything the way they can now," she says. "It’s going to be a huge change. I think it could lead to a lot of hospitals leaving for other accreditation agencies or just going with the Centers for Medicare & Medicaid Services [CMS]."

Leaving the Joint Commission would be a major decision for any hospital, but Mellott says it might start to make sense as the new system puts more pressure on compliance efforts.

The new system will require quality improvement professionals to educate staff and monitor standards compliance to a much higher degree than you do now, Mellott says. That means more work, and you will have to develop a system that allows you to keep compliance high all the time rather than just every three years.

Unannounced surveys will be pilot tested in volunteer organizations during 2004 and 2005; then all surveys will be unannounced in 2006. The change is part of the Joint Commission’s overall improvement of the accreditation process, known as Shared Visions — New Pathways.

Russell Massaro, MD, executive vice president for accreditation operations with the Joint Commission, tells Hospital Peer Review that, starting in 2006, organizations will be surveyed anywhere from two to four years after their last surveys, with surveyors showing up at their doors without warning. They will use "tracer methodology" to follow the experience of actual patients, using those examples to investigate how the organization complied with appropriate standards. The Joint Commission will continue to conduct voluntary unannounced surveys on a limited basis in 2005 and then will transition to a completely unannounced survey program in 2006. An annual 5% sample of health care organizations still will undergo random, one-day unannounced surveys through the end of 2005. After that time, random unannounced surveys will be discontinued.

The new process will require hospitals and other providers to conduct their own self-assessments before surveyors show up. The first parts of the new plan will go into effect in January 2004 for all Joint Commission-accredited organizations. A new survey system with six basic components will replace the standard triennial survey format. Instead of surveyors coming to your facility once every three years to look you over closely, an accredited organization will complete the self-assessment at the 18-month point in its three-year accreditation cycle. Then you submit your own self-assessment ratings by a secure Internet site. For any areas in which your organization is not compliant, you must detail the corrective actions that you have taken or will take to comply. A Joint Commission representative then will review your report, approve it or make further recommendations, and possibly provide advice on how to correct the deficiencies you found. Until 2006 and the unannounced surveys, surveyors will visit the site at the 36-month point, the time for the triennial survey, to verify that the corrective actions have been taken.

Big window in which survey could happen

The two-to-four years after your last survey is a big window in which the unannounced survey could happen, Mellott says. In effect, you will have to be prepared at all times for surveyors to walk in and start assessing you, she says, which is the stated purpose of the switch to unannounced surveys.

Mellott says she supports the intent of the change and believes that it eventually will produce a truer picture of how hospitals comply with Joint Commission standards. She also expects it, along with the upcoming elimination of numerical scores, to eliminate much of the pointless competitiveness that she currently sees among hospitals.

"It’s going to change these situations where you feel like you have to get a 96 because the hospital across town got a 95," she says. "It will cut out that type of competition, which, in my mind, is competition for the wrong reason. It will benefit the industry if we can lose some of the competitiveness and concentrate on what we really need to do to improve our organizations."

Even if everyone welcomes such improvements to the process, the day-to-day work of complying with Joint Commission standards will be tougher and your transition to the new process may be challenging, she says.

The same old ways of doing things won’t be enough in the new process, she says. You’ll need to step up how often you do some things that have worked well before, and you’ll need to develop some completely new systems.

Children’s Memorial Hospital in Chicago will be one of the first to undergo an unannounced full survey in 2004, and so it is among the first to change its compliance process. The hospital requested the unannounced full survey, which will take place sometime in 2004, to demonstrate its continuous compliance and show support for the Joint Commission’s new way of thinking, says Susan Cunningham, MSed, administrator for quality at the hospital. 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.

"I think a lot of us have become very proficient at revving up for the big survey every three years," Cunningham says. "Rather than putting our focus and energy on that, we thought it would be better to consistently be vigilant and ensure that we have systems and processes in place to comply. It’s going to be a major philosophical shift for everybody and will drive the whole concept of continuous standards compliance into the daily work of what we do."

Leaders at Children’s Memorial are focusing more on "constant vigilance" instead of survey preparation, she says.

Instead of working backwards from a triennial survey date to determine when work should begin, hospital administrators are implementing systems that will ensure faster implementation of improvements, says Cunningham, who previously worked at the Joint Commission for four years educating surveyors. "We’re going to have to act on things more urgently, rather than just saying we need to get it done before the survey. This changes the time table, the urgency by which things get accomplished and put in place, whether it’s a new policy or procedure."

One of the first efforts to change the hospital’s compliance strategy was the formation of a guidance team. Made up of key administrators and other leaders in the organization, the members each are responsible for chapters and standards in the Joint Commission manual. The guidance team ensures that self-assessments are performed throughout the hospital and then assesses the results for weak points.

"We were doing some of that already under the old process, but we are stepping up those efforts," Cunningham says. "We’re optimistic about how we would fare under an unannounced survey, but I have to admit it’s a little stressful to think that they will just show up one day without warning."

Could be last straw for some customers

With many hospitals already considering leaving the Joint Commission for other accreditation options, Mellott says unannounced surveys could be the last straw for some. They may opt to rely only on CMS certification, since they have to undergo that process yearly no matter what they do with the Joint Commission.

"There is so much dissatisfaction with the Joint Commission anyway, so I think this might lead to a lot of people just dumping the Joint Commission altogether," she says. "A lot of people are looking at moving on to something else because a lot of them feel like the Joint Commission is getting their hands in a lot of pies and maybe not being able to manage the contents of those pies well."

Leaving the Joint Commission can be a reasonable option for some organizations, Mellott says. But she cautions that you should research the options very carefully before making any decision. Don’t assume that the grass is greener on the other side of the fence.

Relying only on CMS certification, for instance, may sound appealing because there is less paperwork, but Mellott says the CMS process tends to be stricter and oriented to finding problems, not educating organizations about quality improvement.

"I don’t think unannounced surveys alone will make hospitals run away from the Joint Commission, but it could be the last thing that pushes them over the edge," she says.

"A group of factors can lead organizations to become dissatisfied and look for other options, but the switch to unannounced surveys could be the thing that convinces them it’s really time to change. It’s one more thing to make you say, I don’t want to play this game anymore,’" Mellott adds.

[For more information, contact:

Susan Mellott, 5322 W. Bellfort, Suite 208, Houston, TX 77035. Telephone: (713) 726-9919.

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

Susan Cunningham, Quality Administrator, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614-3394. Telephone: (773) 880-4000.]