Surprise! The team’s here for your JCAHO survey

Unannounced triennial surveys start in 2006

Just as we all count on the seasons changing each year, same-day surgery managers have always been able to count on the triennial crush of work to prepare for the accreditation survey. Intense review of policies, procedures, employee training records, physician re-certifications, and other processes, as well as making sure employees are prepared to answer surveyor questions, have always been a part of preparing for a survey.

Same-day surgery programs accredited by the Joint Commission on Accreditation of Healthcare Organizations will no longer be able to prepare for a specific survey date in the next few years because the Joint Commission will conduct all regular accreditation surveys on an unannounced basis beginning in January 2006.

This move is a logical next step in the Shared Vision-New Pathways accreditation process that begins in January 2004, according to Stephen C. Anderson, RN, MBA, consultant for Joint Commission Resources and chief executive officer for Healthcare Information Access in Seattle.

"If you are completing the Periodic Performance Review, previously called the self-assessment, then your same-day surgery program should be in a state of continual survey readiness," Anderson says.

Susan Cunningham, MS, ED, administrator for quality at Children’s Memorial Hospital in Chicago, says her facility volunteered to participate in the pilot test of unannounced surveys because it gives them the opportunity to show that they are always in compliance with Joint Commission standards. "When you know the date of the survey, the survey is really just a snapshot in time of your organization," she says. "The unannounced survey gives you a chance to show that you truly are meeting the standards on a day-to-day basis."

Pilot testing of unannounced surveys will begin in 2004 with 100 hospitals that have volunteered to participate. In 2005, Joint Commission will continue to conduct unannounced surveys on a limited basis for all types of accredited organizations; subsequently, the transition to all unannounced surveys will take place in 2006.

At this time, the Accreditation Association for Ambulatory Health Care (AAAHC) in Wilmette, IL, does not have plans to move to all unannounced accreditation surveys, says John Burke, PhD, executive director of AAAHC. "There are several issues that must be considered when determining whether unannounced surveys make sense for the types of organizations AAAHC accredits," he says. One of these issues is the fact that AAAHC surveyors observe actual procedures, Burke adds. "In the ambulatory environment, surgeries may not be scheduled each and every day," he explains.

Making sure the surveyor is on site on a day during which procedures are scheduled is important to maintain the integrity of the survey process, Burke says.

Whether or not your facility is scheduled to participate in the Joint Commission’s pilot testing, or even if you know you won’t experience an unannounced survey until 2006, there are some things you should do now to ensure readiness, says Cunningham. Set up an ongoing team to monitor standards and any standards changes that occur, and oversee any development of new policies or practices that the standards will require, she adds.

"We have a Joint Commission guidance team comprised of key leaders in a wide range of departments who are responsible for staying up to date on different chapters in the standards manual," she says. Team members also routinely go on "rounds" throughout the organization to ask to see various items or observe employees to see if departments are compliant with standards on a day-to-day basis, she explains. By continuously reviewing compliance within departments, you can ensure that everyone is ready for an unannounced survey, Cunningham says.

Another tip to ensure readiness is for managers and supervisors to query and quiz staff members on a regular basis, Anderson says.

"We are accustomed to concentrating all our efforts to make sure employees know what to do in case of a fire into a short time frame, but then when a surveyors asks someone the question, the employee panics and freezes," he says. "We’ve made sure they have the information, but we haven’t made sure that they are comfortable being asked the question."

If managers and supervisors always are asking the questions, employees get used to answering them and there is no panic, he adds. "Don’t call these questions mock surveys,’ because we want to move away from the mode of preparing for the test and concentrate on continual readiness," says Anderson. Also, use this process as a way to identify educational needs, he adds. "If a manager asks different questions throughout a two- to three-week period, he or she can identify areas in which employee knowledge is weak, provide education, then move on," Anderson says.


For more information, contact:

Stephen C. Anderson, RN, MBA, Consultant, Joint Commission Resources, and Chief Executive Officer, Healthcare Information Access, P.O. 17940, Seattle, WA 98107. Telephone: (206) 795-2831. E-mail:

Susan Cunningham, MS, ED, Administrator for Quality, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614. Telephone: (773) 880-3951. E-mail: