JCAHO advice: Be on your toes for survey

Surveyors arrived on a Friday at 11 p.m.

Barb Maxwell, RN, MHA, COHN-S, CCM, CWCP, and her colleagues had braced themselves for the new survey process of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). They knew they had to be ready for the unexpected. During a recent survey, surveyors arrived at 11 p.m. on a Friday night and asked about security and access to the facility. It was clear this survey was going to differ in style from the past.

Surveyors can show up at any time, any shift. In fact, while last June the HCA hospitals knew about the upcoming surveys, "they no longer have to schedule or announce the visits. They can just pop in any time," says Maxwell, director of company care, occupational health services, for HCA in St. Petersburg, FL. Three HCA hospitals in Florida received JCAHO surveys last summer.

Although the Joint Commission still wants access to your policies and procedures, they have de-emphasized the paperwork portion of the survey. "They don’t spend a whole lot of time reading those manuals," says Maxwell. "They will ask medical records to pull 20 or 30 medical records. They will review those medical records, and they will trace the patients step-by-step through the facility."

For example, if the patient came through the emergency department and then went to radio-logy for X-rays, the surveyors would literally walk through those departments and ask questions.

"They do not talk to any director levels at all. It’s now staff," she adds. "Once the surveyors arrive on the nursing unit, they will find the nurse taking care of the patient and interview them."

The surveyor will call human resources and ask for the nurse’s file to check for competencies.

In occupational health, the surveyors spoke to the frontline occupational health nurses — not to Maxwell. They asked about the process of responding to an injury, and they asked to see the OSHA log. They asked only basic questions: Who signs the OSHA log? How long is it posted?

But the surveyors were watching the staff and observing their use of personal protective equipment. They also asked some employee health-related questions when they visited infection control.

They wanted to know the following:

  • What is the link between infection control and employee health?
  • How do you track and trend employee illness?
  • What are you doing to prevent needlesticks?
  • What is your level of TB skin test compliance?
  • What do you do if an employee doesn’t return to have the test read?
  • How do you handle positive converters?
  • What do you do with employees who have an MRSA infection and wear artificial nails?

In one of the three hospitals surveyed, a surveyor asked what the hospital was doing about annual respirator fit-testing.

"I really thought it was a more thorough survey. There are no stones that are left unturned," she says.

Based on comments from an infection control coordinator and her experience with the surveyors, Maxwell has some advice:

  • Be sure clinical staff know their competencies and they are up to date.
  • Designate someone in each area to perform quality checks, including employee health issues such as proper hand hygiene and proper use of personal protective equipment.
  • Be ready for a survey at any time, including the night shift.
  • Be aware that a surveyor can return. At one hospital, the surveyor had an exit conference, left, then returned to the facility five minutes later.