What quality managers are saying about JCAHO’s new survey process

Newly surveyed assert survey process is tough but educational

Are you worried about your organization’s ability to pass muster with the Shared Visions — New Pathways survey process from the Joint Commission on Accreditation of Healthcare Organizations? If so, it’s the moment of truth.

Hospital Peer Review put the new process under the microscope by interviewing quality managers at four facilities surveyed in early 2004. By all accounts, you can expect enhanced education for frontline staff, but if you’re betting on being able to fix problem areas on the spot before surveyors find them, think again.

That’s because the new process is a true litmus test designed to identify areas in need of improvement, says Mary M. Owen, RN, MPA, director of outcomes case management at University of California, Irvine Medical Center in Orange.

"It is more collaborative and consultative and very thorough," she adds. "There is no way to hide or clean up things as you go, because the survey process moves much too rapidly through the organization."

In fact, surveyors will know a great deal about your trouble spots before they even walk in the door. "They arrived having read our priority focus process summary and were familiar with the priority focus areas and clinical service groups selected for the hospital," reports Mary B. Bergerson, resource specialist for performance improvement at St. Helena Hospital in Deer Park, CA.

"The new survey process will give the Joint Commission a more true picture of what really happens in the hospital," adds Jane Gordon, RHIT, director of quality at Harford Memorial Hospital in Havre de Grace, MD. "There was no opportunity to put on a show for the surveyors."

Here are reports from four facilities surveyed in early 2004:

Expect less interaction between surveyors and medical staff.

The medical staff interview has been removed from the schedule, says Lynne Adams, CPHQ, director of quality at Upper Chesapeake Medical Center in Bel Air, MD. "There was no schedule for which patients or which units the surveyors would go to or when they would go," she explains.

As a result, the community practice physicians were mostly unavailable when surveyors arrived on the unit. In the few instances when a physician was available, the surveyor didn’t ask to speak with him or her, Adams adds.

Since the chiefs of the emergency department (ED) and operating room (OR) are full-time staff, they were present, and the surveyor did interview them. However, the chiefs of other departments including medicine, surgery, obstetrics, and pediatrics are practicing physicians, so without an agenda, it was unreasonable to expect them to be available for four consecutive days, she says.

There isn’t always an off-shift survey.

"We were surprised that there was no evening or night-time survey during our four days," says Adams. "One of the surveyors let us know that the requirement for an off-shift survey is now based on what is found during the daytime survey activities."

Surveyors took an educational approach.

Several times, surveyors clarified that they were giving consultative information and weren’t stating findings, and they went on to give advice for improving compliance, Bergerson says. For example, surveyors made suggestions to the medical staff for improvements in the peer review and proctoring processes.

The surveyors were very good about educating staff when they found anything that could be done better on the unit, Gordon says. "They were approachable and did a good job of making the team members feel at ease," she adds.

For instance, when the physician surveyor reviewed procedures for moderate sedation, he immediately suggested a better way to prompt care providers to give patients pre-sedation assessment. "He had seen this format at another hospital, and it made sense for us," Gordon says. "The change was made and approved at the next medical executive committee meeting."

Similarly, when the surveyor noticed a couple of dirty vents at University of California, Irvine, he suggested that this probably was caused by recent fires in the area and suggested a system for more frequent cleaning of the vents, Owen reports.

Patient and systems tracers worked as expected.

The Joint Commission’s Priority Focus and Tracer Methodology video (part of the Shared Visions — New Pathways video information series) does an excellent job of outlining what to expect, according to Adams. "The video very closely resembled our survey process," she says.

Here are the steps that occurred for each patient tracer:

  • The surveyors identified the type of patient they wanted to see by diagnosis and length of stay, and a patient was selected from the daily census.
  • At each unit, the surveyor was introduced, taken to the patient’s nurse, and given the chart to review. The surveyor interviewed the nurse and usually asked to speak to someone from the different disciplines who had worked with the patient, such as a physical therapist or dietitian.
  • If the patient had been on more than one unit, the surveyors traced back through those units, going to a unit as many times as they felt necessary. "For example, the three surveyors visited the intensive care unit seven times in four days — at one point, all three surveyors at once." Adams says.

Unit staff were asked direct questions.

Surveyors asked very pointed questions of unit staff, in sharp contrast to previous surveys, when organizational leaders answered the vast majority of questions, says Gordon. "They asked the same questions on every unit they surveyed, so they truly saw whether our answers reflected the hospital policies and practices and weren’t just rehearsed answers."

Staff clearly could see the value of the survey process because they were so closely involved, Gordon says. "There has been much more discussion among the team members after the survey than I have ever seen before," she adds.

Although frontline staff weren’t used to being the focus, they were asked in a way that wasn’t intimidating to explain various care processes, Adams notes.

Staff were able to speak in terms they were familiar with, and it was the surveyor’s job to determine whether the standards were met. "Team members didn’t have to recite the Joint Commission lingo, but the surveyors listened to the process in the context of whether or not it met the intent of the standards," she says.

For instance, instead of asking staff about "core measures" specifically, surveyors asked them to "tell me what you’re doing to improve the care of your patients with congestive heart failure."

The tracer process places the focus on frontline staff and the consistency of various patient care processes, Bergerson says. "Since safety and quality of care are the primary areas of concern for caregivers as well, they were very engaged in and supportive of the new survey process," she says.

After arriving at each unit, surveyors reviewed the medical record, noted the patient’s flow through the organization, and checked for timely placement of information such as history and physical, laboratory results, and consultation reports.

"The surveyor then asked for the nurse or clinician who had primary responsibility for taking care of the patient," Bergerson says. "This staff member was asked to summarize the patient’s history and plan of care."

Numerous questions were asked about processes such as medication administration, patient identification, infection control, coordination of care between disciplines, competency, taking verbal orders, data regarding medication variances, and other quality initiatives. "Occasionally, the surveyor asked to see the staff members’ competencies, license, or other certifications during the interview process," Bergerson says.

Surveyors compared notes.

At the end of each day, surveyors checked with one another, looking for any problems with compliance, flaws in process design, or inconsistencies in existing processes. Any areas of concern were investigated through additional patient tracers, review of closed medical records and personnel files, policy and procedure clarification, scheduled interview sessions, and systems tracers.

After performing a few tracers, surveyors wanted an in-depth look at patient education at discharge, especially as it related to patient safety at home. "The surveyors requested several closed medical records, asking for patients who were admitted at specific dates and times," adds Bergerson. "Although they did not say why they wanted the medical records, it became apparent. Fortunately, they found what they were looking for," she continues.

Less time was spent on documentation review.

The new tracer methodology focuses on delivery of patient care instead of retrospective review of documentation, Bergerson explains.

"The emphasis is on processes which ensure patient safety and quality outcomes, as opposed to the review of written documentation," she says.

Surveyors requested an operating room log, emergency department log, cath lab log, and current census with diagnoses for their morning planning session, Owen reports. "Additionally, the only time we had to pull retrospective records was with respect to narcotic logs and wastage documentation, and that was very limited," she says.

The request for documents was onerous in the past and typically required a minimum of two weeks of preparation to get all the necessary binders together, Owen says. "This time, there really was no preliminary request for documents other than the statement of conditions. It’s much simpler than in the old days."

[For more information on the new Shared Visions — New Pathways survey process, contact:

  • Lynne Adams, CPHQ, Director, QHIM, Upper Chesapeake Medical Center. 500 Upper Chesapeake Drive, Bel Air, MD 21014. Phone: (443) 643-2510. E-mail: KLA.02@ex.uchs.org.
  • Mary B. Bergerson, Resource Specialist, Performance Improvement, St. Helena Hospital, 650 Sanitarium Drive, Deer Park, CA 94576. Phone: (707) 967-5813. Fax: (707) 967-5744. E-mail: BergerMB@ah.org.
  • Jane Gordon, RHIT, Director of Quality, Harford Memorial Hospital, 501 S. Union Ave., Havre de Grace, MD 21078. Phone: (443) 843-5817. Fax: (443) 843-7940. E-mail: JEG.01@ex.uchs.org. Harford Memorial Hospital.
  • Mary M. Owen, RN, MPA, Director, Outcomes Case Management, University of California, Irvine Medical Center, 101 The City Drive, Orange, CA 92868. Phone: (714) 456-8964. E-mail: mowen@uci.edu.]