JCAHO has beefed up training and education
Surveyor profiles match abilities, needs
"In the end, [the survey process] is about delivering service," according to Russell Massaro, MD, executive vice president for accreditation operations at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. He says 650 surveyors perform 7,000 to 9,000 surveys a year at more than 18,000 organizations.
Massaro told Hospital Peer Review that issues surrounding the education of its surveyors are very important to the Joint Commission. The agency evaluates surveyors’ performance annually, Massaro says. JCAHO also evaluates itself on how well the agency addresses competency and skill-building. He says each surveyor’s performance is "rated against standards of performance and evaluated by criteria of competency." The agency analyzes data collected from surveyors’ evaluations and looks at organizations’ comments. And, as in any other company, the surveyors’ supervisors work with them on a continuing basis to improve their performance.
"We’ve done more in surveyor education over the past three years than I’ve seen prior to this," says Ann Kobs, sentinel events specialist in the division of accreditation operations for the Joint Commission. "There’s two and a half weeks of training to start. Then new surveyors go out supervised by preceptors until all of their objectives are met. Then they’re on their own, except that we have nearly daily phone, voice mail, or e-mail contact with them to update them on policy changes." The surveyors undergo continuing education through distance learning. "We give them self-learning packets and audio tapes, and their new laptops have CD-ROMs so we can send interactive learning disks to them as well."
All full-time surveyors go to an annual meeting in Chicago the first weekend in January. "We bring together a large amount of data for our annual surveyor training curriculum," says Massaro.
In addition, every other year for the past five years, the agency has commissioned a consulting group to do defined market research on a large sample of accredited organizations. The consultants ask principals their perception of the survey process. Also, every year there’s a CEO opinion poll on the work of the surveyors and the value of accreditation in general.
Joint Commission board members drop in on surveys periodically and directly observe. "We’re attempting to expand those unannounced drop-ins in 1999," says Massaro.
The laptops and software supplied to surveyors for scoring have enabled the survey process to take a quantum leap toward improving objectivity, reliability, and consistency across the country, Massaro says. The Joint Commission has just finished bringing up all seven accreditation programs to the laptops. "But there’s always room for improvement," he says.
Kobs adds, "Often I’ll get a call from a surveyor saying, This is what an organization is claiming, and this is what I’m seeing. These things don’t jive.’ I’ll ask to talk to someone in the organization to straighten things out. We’re in very close contact with them."
Some Hospital Peer Review readers wanted to know if there’s any way a hospital can choose a favorite surveyor. Massaro says no: "For one thing, surveyors are based in four geographic regions, and to control costs, we minimize the travel a surveyor does." Scheduling takes into account those locations and a surveyor’s specialty — mental health, ambulatory, and so on. A physician and a nurse might be needed in one area, and an administrator, nurse, and laboratory specialist in another. "As organizations come up for survey, their locations and types drive the selection process," he says. "We go to the pool of surveyors by discipline and availability."
The Joint Commission has just finished reprofiling surveyors, including in-depth background commentaries on academic appointments, special interests in which they’ve done research, and special settings in which they’ve worked, such as VA hospitals, prison hospitals, or Armed Services facilities. Programmed into the agency’s computers are data on work in foreign countries and ability to speak different languages. "Now we can look at the range of our organizations and try to add their needs to our selection criteria," says Massaro.
Part of training deals with relaying bad news’
Hospital Peer Review asked Massaro how surveyors are rated. "The issue is not who is the best surveyor or the worst," he explains. "What we evaluate is their performance and improvement over time." The Joint Commission first establishes performance goals and objectives for each surveyor. The goals fall into three major categories:
• Competency. A surveyor’s competency has to do with an accurate and thorough knowledge of the standards; an accurate and thorough knowledge of the methods of surveying and assessing standards in each health care setting; and an ability to identify noncompliance with standards and score accurately according to scoring guidelines.
• Routine employee behavior. This has to do with a surveyor giving the Joint Commission the availability that has been contracted, following company policy and procedures, dressing appropriately, and so on.
• Perception. An organization’s perceptions of a surveyor are in part related statistically to the score the organization gets at the time of survey. There is a defined correlation between the number of recommendations that a surveyor gives and the complaints about the surveyor.
"We have to be careful not to overinterpret that data one way or another in relationship to a surveyor’s abilities," says Massaro. "We don’t discount that. It’s a major challenge that we take seriously." In addition to understanding the potential relationship between the surveyor not telling the organization what they want to hear and the organization complaining about the surveyor, issues about the surveyor still must be accounted for in his or her evaluation. "We try to have a balanced view and understanding of it," he says.
What’s more important is the nature of the surveyor, says Massaro. "If an organization gets a good score and yet provides specific and detailed negative comments about a surveyor, that’s taken seriously." In the other situation, where the organization gets a less than favorable score, the negative comment is still taken seriously, but the question becomes, "How do we assess the relationship of that to their score?" The answer lies in what specific data the surveyor found and how he or she documented and scored them, Massaro says. If a surveyor’s judgment about a standard seems to be correct, then the agency has to assume the surveyor was just doing his or her job.
Part of a surveyor’s training deals with relaying bad news. "There are two ways," says Massaro: "the professional way and the arrogant, uncaring way. The latter is not tolerated.
"And certainly if an organization alleges that a surveyor engages in inappropriate behavior of any sort, we take that very seriously and aggressively investigate that situation."