Get ready for JCAHO: Know the latest hot topics

Being informed about JCAHO's current areas of emphasis gives ED managers an advantage when undergoing a review

Successfully getting through a review by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is never a simple task, but knowing what surveyors are currently scrutinizing makes it a lot easier. "It's extremely important to know what their focus is around the time you're about to be surveyed," says Gail Anderson, MD, FACEP, senior vice president of medical affairs and chief of staff for Grady Health System in Atlanta, GA, and ACEP's liaison to the professional and technical advisory committee of JCAHO's Hospital Accreditation Program.

Managers have the advantage of knowing the date and time when the surveyors will arrive in the ED several weeks in advance, which can help in strategic planning. "You should be sure to have your star performers working on that day," she advises.

Another key piece of information is the name and background of the surveyor. "In the past, we've had a urologist, neurosurgeon, internist, cardiologist, and will have an ear, nose, and throat specialist for an upcoming survey," says Anderson. "Because of the wide variety of backgrounds, there will be some areas they have a particular interest in."

Contacting other hospitals that were reviewed by the same surveyor is a strategic move, she notes. "There is absolutely no prohibition against doing that, and it can shed light on the types of questions that particular surveyor has recently asked," he says.

JCAHO are not police

ED managers report that JCAHO surveyors have become "kinder and gentler" in recent years. "There has been a definite shift in the way surveys are conducted. "It's no longer a policeman approach, but more of an educational approach," reports Anderson.

There is an overall emphasis on performance improvement, with surveyors frequently giving constructive feedback. "You still need to comply with the appropriate number of fire exits and all the other basic regulatory issues," she says. "But now, surveys are more of a dialogue that goes back and forth, instead of a person with white gloves on checking for dust and marking down a demerit."

Still, most ED managers become anxious at the prospect of a survey. "Passing this has a lot of significance, so it's only human nature to be worried when somebody is going to make an appraisal of your ED," notes Anderson. "But, we need to recognize this as an ongoing process of improvement which we can learn from."

Passing a survey with flying colors should be a source of pride for ED staff, she continues. "The review should drive us to continue to make sure our benchmark standards of care are being upheld. Being given a seal of approval by Joint Commission is a definite sign of measuring up to those standards."

Survey is opportunity, not threat

A Joint Commission review should be viewed as an opportunity, says Kym Salness, MD, FACEP, director of the emergency medicine center at the Milton S. Hershey Medical Center in Hershey, PA. "Unfortunately, it's frequently regarded by the medical staff as some kind of onerous task they have to gear up for and avoid if they can possibly get away with it," he notes.

Emergency physicians should take the opposite approach and avoid looking at survey preparation as a burden. "Getting ready for JCAHO is part of our job and comes with the territory," stresses Salness. "Still, there are some ED directors who try to figure out how they can get out of this, which is detrimental to their leadership position and the care they are delivering."

It's essential to update all policies and procedures regularly. "Your policy on how the ED will function in a regional disaster can't be dated 1975," says Salness. "All ED policies need to be updated continuously and signed off on by leadership."

It's a mistake for ED directors to shift the burden of JCAHO preparation to the nursing staff, Salness emphasizes. "Too often, nursing leadership gets saddled with the entire responsibility, which is an inappropriate and unfair load to place on them," he says.

Physicians need to collaborate with the nursing staff to gear up for JCAHO. "You should be able to show surveyors that your QA programs are tied together in a cooperative, professional, interactive process that appropriately uses the combined leadership of the ED," says Salness. "The doctors won't look good without the collaboration of the nursing staff, and vice versa."

Nursing and physician leadership should both insist on attending the survey. "This is your show for a half a day, and it's not a task you can leave to somebody else," says Salness. "Tell your administrator you'll be there, no matter what day it is."

Ongoing quality assurance is the best preparation, Salness stresses. "All physicians in the ED should participate in QA, not just once every three years for JCAHO, but continuously," he says. "That should include reviews of lengthy delays, medication errors, unexpected deaths or all deaths in the ED, and focus studies of various parameters, such as adherence to conscious sedation protocols or documentation of non-pregnancy in women before X-rays are taken."

Take a team approach

Having knowledgeable clinicians present during the survey is a major asset. "If you can have physicians there talking about patient care, it's extremely impressive," says Judy Maupin, MSN, RN, CNAA, senior advisor of clinical services at Columbus Regional Hospital. "It's an absolute must for the chief physician and medical director to both be present. If they can't be for some reason, they need to have a replacement who really knows the department."

Key staff members should be introduced to surveyors and actively participate in discussions. "One individual should not do all the talking. Include the nurse director and other staff members," says Anderson. "Encourage them to jump in and show some enthusiasm about the work you do. That will send a message to the surveyors that you have a vibrant program you are proud of."

Select staff who are both knowledgeable and enthusiastic. "Often people become intimidated around surveyors," says Anderson. "Try to include individuals who are not reticent about talking."

Brief, concise answers should be given in order to allow the surveyors to ask follow-up questions, Anderson recommends. "Be wary of getting into controversial areas, and don't monopolize the conversation," he says. "Try to answer the specific question they ask."

At the Medical University of South Carolina, weekly handouts are distributed to ED staff on key topics before a JCAHO survey. "That helped to keep people informed about what we were doing as an institution related to the survey," says Mary Anderson, RN, BSN, nurse manager of emergency services.

A list of sample questions was developed to quiz staff members during weekly meetings in the weeks prior to the survey. "I used the questions in the Joint Commission guide to quiz my staff," she says. "It helps them to be less intimidated if by chance somebody does ask them a question."

Any staff member should be prepared to answer survey questions. "They asked me how often our housekeeper changes the red bags, and I told them they were checked twice a day and changed at least that often," says Anderson. "Then, later in the survey, they asked a housekeeper the same question, to make sure we both knew the policy." The surveyors were satisfied when the housekeeper gave the same response, she notes.

Staff should be familiar with the scope of services provided in the ED. "You may not see psychiatric or burn patients in your department," says Dr. Anderson. "If all staff are familiar with that, that will potentially help the surveyor move on to the next item of interest and not get them delayed unnecessarily."

Staff members should not hesitate to show pride in the ED's accomplishments. "Think about what you are proud of, such as quality improvement activities, that you can brag about," suggests Dr. Anderson. "But, present them in quantifiable terms. Instead of saying you formed this committee to reduce waiting times, tell them you were able to reduce waiting times from 22% from the previous year, and have the backup data should the surveyor want to probe further."

Anticipate problem areas in advance. "If your ED has a number of community complaints, or you were cited in the previous year through a sentinel event, be prepared to show what steps you've taken to rectify that," advises Dr. Anderson. "If you have difficulties taking care of pediatric patients because you don't have a pediatrician on staff, let them know if you have made arrangements with another hospital to address that."

Don't waste the surveyors' time. "You should move them through as quickly as possible, since sometimes they are running behind," advises Dr. Anderson. "Surveyors might ask to see a chart or talk to someone on staff, but you shouldn't get hung up in areas where there is a significant amount of clinical activity."

Avoid using the survey as leverage to obtain additional resources from your administrator, cautions Dr. Anderson. "Don't use it as an ax-grinding session, to accomplish some personal agenda item in front of the surveyor," he says. "Trying to get the surveyor to push for something you want done typically backfires. They may not have the whole story. Also, it does not do anything to win you support from your colleagues."

JCAHO hot topics

Here are 15 current "hot topics" with JCAHO and ways to address each.

Abuse and neglect. Recognition and reporting of child, sexual, and elder abuse is a major focus of surveyors. "In your policies, you need to have identified criteria that would signify abuse, which trigger staff to recognize potential abuse," says Mary Anderson. In cases of abuse, surveyors will want to see that some action was taken and documented on the patient's chart, she notes.

Staff also need to demonstrate knowledge of the steps to take if abuse is identified. "Any staff member should be able to describe how you work with outside agencies, such as adult protective or social services, and demonstrate an awareness of the resources in your community," she explains.

Patient transfers. EDs need to demonstrate compliance with federal EMTALA regulations. "Surveyors will scrutinize how you make arrangements for transfers, staff familiarity with regulations, and how you ensure that patients are informed and in agreement," says Maupin.

Patient education. There is a focus on efforts to educate patients and their families. "Closed medical record reviews must consistently demonstrate that the patient's or family members' learning needs, abilities, and readiness to learn were assessed," says Barb Pierce, MS, RN, divisional director of emergency services at Children's Hospital of Alabama in Birmingham.

Documentation concerning verbal and written education is key. "If you gave a patient standard written materials, and the next day you have a follow-up phone conversation, you should have a telephone log which documents that," says Thomas Sonderman, MD, FACEP, medical director of the ED at Columbus Regional Hospital (IN). Surveyors also look for availability of interpreters or multilingual instructions, and discharge instructions geared to a sixth grade reading level, he adds.

Patient safety. "Surveyors are very interested in the security of your ED, which includes controlling access from the waiting room," notes Sonderman. Acceptable solutions include patient-visitor representatives to escort people back and forth, or security doors to control access in and out of the ED.

Patient confidentiality. "Surveyors understand there is a certain amount of privacy violated simply by virtue of being in the ED, especially if you have all open bays with no private rooms, but there are still things you can do," says Mary Anderson. "For instance, they want to see that charts are kept in a private area with no access to patients or families, and that patients are gowned properly."

Surveyors are looking for an overall awareness of a patient's right to privacy. "You need to build a culture of respect for patient privacy and consider confidentiality of paramount importance," says Sonderman. If exam rooms have a door, surveyors want to see that staff members close doors quickly as they enter and exit, and always knock before entering, he adds.

Keeping conversations at the triage desk confidential is a key concern for surveyors. "Clinicians should never speak flippantly when medical information is being discussed, and should make a conscious effort to keep their voices low," says Sonderman. Installing sound absorbent material or glass panels, isolated interview booths, or background music systems to create a white-noise effect, will show surveyors that the ED is addressing the issue, he says.

Intradisciplinary involvement. Surveyors want to see seamless care throughout the hospital. "For a patient with an acute MI who needs thrombolytic therapy, they will look at the entire process, going all the way from the patient's home through the inpatient stay," says Sonderman. "Then they want you to show them how that continuum of care translates into less morbidity and mortality for that patient population."

Graphs or charts that measure various aspects of the patient care process are helpful, says Sonderman. "Show them data on how long it takes you to get the data you need, for the physician to make the decision to give thrombolytics or for the staff to administer them," he says. "Capturing those sort of data elements allows you to see where your problems lie and allows you to improve."

Identifying backlogs and acting to solve them impresses surveyors. "For example, if you find out it's taking 20 minutes to get an ECG completed, and you resolve that bottleneck, you can show them that your data revealed a reduction in door-to-drug time by 30%," says Sonderman.

Critical pathways used in the ED should have a multidisciplinary approach. "Input is needed from all departments to develop a best proactive initiative," says Sonderman. "Having that occur at the quality management committee level shows that approach is taken across departments and across specialties."

Informed consent. Surveyors want to see that patients are fully informed. "Open and closed medical records must contain sufficient documentation of patient's awareness of the risk, benefits, and alternatives associated with a planned operative or invasive procedure," says Pierce.

Sentinel events. A sentinel event involves an unanticipated death or serious physical or psychological injury. "Sentinel events must have an intense, systematic process to review undesirable variation in performance," says Pierce. "The intensity is the key here. They want to see that a root cause analysis was completed."

Universal precautions. Surveyors want to know that staff are following universal precautions. "They will look in HR files for records of orientation, and watch the staff while they are there to make sure they are following the requirements," says Maupin.

Medication control. All aspects of medication control are currently being emphasized, due to publicity over the high incidence of medication errors in hospitals. "They want to see how you sign out narcotics and whether you have them in the trauma rooms where the public could get to them, which is a no-no if they aren't locked.[They also want to know] and how do you know the right drug is dispensed to the right patient at the right time," says Maupin. Surveyors may check crash carts for expired medications, or pull specific patient care records, she says.

Refrigerator temperature. Surveyors may check temperature logs for ED refrigerators. "If the logs show that one day the temperature was outside the acceptable range, they will want to know what you did about that," says Maupin. "They will want to know how long the drugs were out of range, since it can potentially damage drugs."

The hospital pharmacist should be present to respond to these questions, Maupin suggests. "It's a very strategic move to have the pharmacist speak to those concerns, since it would be their decision if the drugs needed to be destroyed," she says.

Don't mix food and medications in ED refrigerators. "And even if a refrigerator is just used for food, you need to keep a log on it too, since spoilage of food is considered a source of contamination," Maupin notes. "They are looking for everything in there to have a name, label, and date. If it doesn't, it has to be tossed."

Restraints. All staff should be familiar with the ED's restraint and seclusion policies, and be able to demonstrate compliance with regulations. "Restraint is a very hot topic this year," says Mary Anderson.

At Medical University of South Carolina, all the information needed for restraining a patient was put onto a stamp plate. "As soon as the nurse restrains the patient, we stamp the form, and a physician circles what was needed," says Mary Anderson. "It was an inexpensive yet effective way to tackle that problem." A form was later developed to record the information, which surveyors were impressed with, she adds.

A restraint task force at the Joint Commission is currently revising standards that will appear in the 1999 manual. "It still has to be field-tested this summer and approved by the board, but I suspect we'll see a recognition that the notion of a totally restraint free ED is not practical," says Dr. Anderson. "We'll also see more of a distinction between the psychiatric areas and the rest of the hospital, including the ED."

AMA patients. It's useful to know how your ED's AMA rates compare nationally. "If you exceed the average national rate, surveyors will want to know why. Was the ED so overcrowded that patients were unable to get care?" says Dr. Anderson. "They may also ask if you have a mechanism to follow up with AMA patients if abnormal lab results or X-rays come in after the patient has left. Be prepared to address this in case it comes up."

Consistent care. Surveyors want to see policy manuals that ensure continuity of care. "They want to see that your hospital guarantees that ED patients will receive the same level of care as admitted patients do in the ICU or floors," says Mary Anderson. "You can adapt hospital policies to your ED, but they need to be based off the same policy as other departments are using."

Employees records. Often, surveyors will pull an employees file for inspection of orientation, competencies, and evaluations. "Usually it's the nurse manager's file, but this year they asked when my peak time of patient flow was, and asked for a nurse who works during that time frame," Mary Anderson says.

It's helpful to demonstrate that staff competencies are current without going through multiple files. "Our staff needs to maintain ACLS, PALS, and TNCC as a baseline to be employed here. We put all their competencies on a spreadsheet to show surveyors everyone is up to date," she says.