Is your accreditation at the mercy of a surveyors’ mood or agenda?

Some quality directors say this is often the case

Although the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) generally gets high marks for the education and training of its surveyors, the survey results your facility gets too often hinge on the mood or pet peeves of the surveyor, according to quality directors interviewed by Hospital Peer Review.

Indeed, while some acknowledge that the Joint Commission has come a long way in the past few years in bringing its surveys and surveyors up to speed and making the process consistent and fair, others question whether the agency has gone far — and fast — enough.

Terry L. Weldon, Joint Commission coordinator at Pardee Hospital in Hendersonville, NC, says he’s been seeing positive feedback on specific surveyors. "They were tough but fair when they came to Pardee," he says. "They were thorough and left no stone unturned. They educated us." (See related story on how the Joint Commission trains and evaluates surveyors, p. 216.) But, he adds, "The Joint Commission’s not quite there yet. Its standards department sometimes gives advice that conflicts with that of the surveyors. The agency and surveyors should be on the same page."

Sandra Sessoms, RN, CPHQ, assistant vice president of nursing, quality improvement, and utilization review at Suburban General Hospital in Pittsburgh, says she too believes there sometimes are disagreements between Joint Commission headquarters and field surveyors. "An outcome can depend more on what particular surveyor you have," she says, "than on how well your facility measures up." Why else, she wonders, would Joint Commission headquarters disagree with a decision made by a surveyor? At Suburban’s last survey, there was a problem with some questions on restraints, but when Sessoms sent in a rebuttal to the surveyors’ decision, headquarters reversed it.

Most facilities have had that experience. It’s usually good news when decisions are reversed, but looking at the larger picture, is it a failing on the surveyors’ part when a facility is able to appeal and negotiate Type 1s with the Joint Commission? Is it a sign that the left hand doesn’t approve of — or just doesn’t know — what the right hand is doing? A quality director who wishes to remain anonymous says the surveyors merely collect data and score them according to fairly objective scoring methods, and it’s the accrediting organization that makes the final decisions about Type 1s. "Once they assign a three, four, or five, though, you’re in Type 1 territory," she admits.

Her organization had a surprise in 1994: The exit survey was positive, but then the facility wound up with 13 Type 1s. The team successfully negotiated the removal of about nine of them. How does it happen that you think you’re doing fine, then wind up with Type 1s? "There was a technical detail around the coordination of the input of the different surveyors," says the quality director. "That can happen."

"Also," says Sessoms, "I’ve heard from peers at other hospitals that even when they feel they’re not very well prepared, they have gotten 99s. A lot of it seems based on how well you can talk and present yourself." Some of the proof is in the pudding, of course, with chart reviews and other substantial evidence, but a lot of the surveyors’ decision making seems to be based on how well certain issues are discussed and how well certain questions are answered, say some of your colleagues.

"Why should your score depend on the attitude of the surveyor?" asks another quality director who also prefers to remain anonymous. "We had a random unannounced survey midcycle recently, and our surveyor was wonderful. He exemplified the educational mode. When he looked at our last survey, he was surprised at what a tough surveyor we must have had that year." The surveyor repeatedly told the staff that their last surveyors had been uncommonly tough on them.

"I thought that was strange," the quality director says. "In a way, we felt better, because we had received a few Type 1s last time and ended up at about 90, and we wanted to do better than that. But in other ways we were confused." Her experience made her wonder about consistency among surveyors. She says she thinks there’s a lot of variation in how standards are interpreted.

"Here’s a good example," she says. "When we were surveyed in 1996, our physician surveyor picked up a file and said he didn’t even have to look at what was inside. He went on to tell us how we did our affiliated health credentialing and our quality profiling. He was right, probably because he had seen it so much, but my point is, he’d made up his mind without looking at our file. How fair is that?" But she adds, "I know the Joint Commission is working hard on consistency problems."

"What’s happening in the field is not always what the standards interpretation office is telling us," says Susan Mikolic, quality standards specialist at Lake Hospital System in Painesville, OH. She says she and her team have spent a lot of time and energy working around surveyors’ idiosyncrasies and identifying which issues are unique to which surveyor. "We try to cover ourselves and go the extra mile," she says. For example, she asks, do we really need thermometer logs on staff refrigerators? "It depends on what surveyors you have. To me, it’s not worth risking a Type 1 for not having one when you can throw a piece of paper on a refrigerator to avoid it. I say, buy the dollar thermometers, put the temperature logs on there, and the problem will go away, and the next surveyor won’t be looking for that."

But Mikolic says there was more of a problem 10 years ago than there is today. She says she feels the Joint Commission has made a serious commitment to improving reliability and consistency among the surveyors. "It’s much better now," she says, "but there are still human nature issues."

Surveyors go in with biases’

Patti Higginbotham, RN, CPHQ, director of quality improvement at Arkansas Children’s Hospital in Little Rock and a new member of Hospital Peer Review’s editorial board, reinforces the view that surveyors are human and that everyone has a bad day occasionally. "Surveyors go in with their own biases," she says. "They have certain items they are particularly interested in, and they think those are critically important. As they go along the survey trail, they begin to focus in on favorites."

Higginbotham is quick to add that she thinks the Joint Commission has "brought a lot to the quality field that we wouldn’t have were it not for them. Our whole interest in QI and QA is something they made us do. It’s important to have them there making sure we’re doing a good job and at least meeting minimal standards. I have no problem with that."

Without a doubt, personalities figure in. "They’re only human," says Russell Massaro, MD, executive vice president for accreditation operations at the Joint Commission. Some surveyors seem to bend over backwards to help, says one quality director. "We were headed toward a Type 1 last year that we knew we would get, but the surveyor helped us. We had a problem with verbal orders, and he said, You have three days, while we’re here, to get yourselves out of this problem. Get all the records together that you need to change the outcome.’"

JCAHO listens more carefully now

Steven A. Muller, MD, senior vice president for medical affairs at Covenant Health System in Waterloo, IA, says any improvement in the Joint Commission has been due to its willingness to listen to its constituents. "The big objection I have," says Muller, "is that there are still some bad apples."

He says there should be a difference between a survey and an inspection. "During a survey you have the right to dialogue and talk about things back and forth. The premise of an inspection, in my mind, is I’m going to find something wrong with your organization.’"

Muller says that 18 years ago, undergoing a Joint Commission survey was a lot simpler than it is today. "You put people in a room and sent them a lot of papers. They walked around the hospital, measured a few items, walked back to the room, and that was the end of it."

He says the overall quality of the surveyors is significantly enhanced today. "They take a much more collaborative, educational, and informational kind of role now, and are much less in the role of traffic cop. We had a very congenial relationship with our surveyors last time around."

When it comes to whether the Joint Commission pays surveyors adequately, or if a part of their problem is inadequate incentive, some of your colleagues say, "You get what you pay for." According to some, if the Joint Commission paid its surveyors better, it would attract more reliable, more experienced, and more educated people. Hospital Peer Review asked Muller what he thought on the issue. "My understanding is that the Joint Commission pays physicians $240 a day — that’s $30 an hour or about $62,000 a year. I do question that. That doesn’t sound like the kind of compensation most physicians would be willing to work for."

Covenant’s fees for the Joint Commission this year came to about $100,000, Muller says. The system is composed of three hospitals, 20 ambulatory sites, a home health agency, durable medical equipment, and two pharmacies.

"Surveyors used to be retired health care professionals, for the most part," says one quality director, "but I think the Joint Commission is trying to move away from that. The agency is trying now to attract younger, more active people, individuals who are working regular hours at their day jobs’ on top of their surveyor jobs."