Once you merge, the countdown starts

One year until your policies should match

Beware: Once you merge with another facility, the clock starts ticking. After one year, surveyors from the Joint Commission on Accreditation of Healthcare Organizations are likely to examine whether you have uniform policies and procedures in your case management department.

"The Joint Commission sees you as one entity," explains Cheryl Sangermano, RN, BSN, CNOR, director of ambulatory surgery at Grant Medical Center in Columbus, OH. Grant Medical Center and Riverside Methodist Hospital, which previously were separate entities within the Ohio Health system, merged in the summer of 1996. Grant underwent a mock Joint Commission survey in June 1997.

"Their comment to us was that, 'You have a one-year honeymoon. Then we see you as one, and your policies and procedures have to be the same across the board,'" Sangermano says.

On the record, while Joint Commission staff says there isn't a hard-and-fast timetable regarding merged policies and procedures, there are expectations. "It would depend on the policy and depend on where they are in the process" of merging, says Paul VanOstenberg, DDS, MS, director of the department of standards. "Were they just acquired in the previous months? Our expectations are lower. If it was a year ago, our expectation would be that everything would be aligned. It depends on what's reasonable for the organizations."