JCAHO halts advance notice of random surveys

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in Oakbrook Terrace, IL, will stop giving notice of random unannounced surveys to organizations starting in January. It is one of several major changes to the Random Unannounced Survey Policy that JCAHO made during its July board meeting.

Other changes include creating a nine- to 30-month window of time after a triennial survey during which random unannounced surveys can be conducted. JCAHO also announced that the scope and focus of review during an unannounced survey will vary from organization, and will be based on information relating to recommendations made during the organization’s previous triennial survey, known sentinel events, and other relevant information regarding the organization’s performance.

Until January, the policy remains the same: Unannounced surveys will happen at the mid-point of an accreditation cycle; they will be preceded by a 24-hour advance notice; and standards to be reviewed will be communicated prior to the survey.

"These changes stem from research conducted with accredited organizations, various groups who rely on Joint Commission accreditation decisions, and Joint Commission surveyors," says Dennis S. O’Leary, MD, president of JCAHO. "We believe they will make our overall accreditation process more meaningful and credible."

Other accreditation process improvement initiatives discussed by the Board of Commissioners at its July meeting include:

• The development of a pre-survey information packet that will provide surveyors with specific information about the health care organization’s performance and permit exploration of any performance issues during the survey.

• Pilot testing of the extension of the on-site survey to evening, night, and weekend periods. Currently, Joint Commission survey activities, including most unannounced surveys, are conducted during regular daytime hours. The pilot testing of off-hour evaluations will begin during the last quarter of 1999 and extend through the first quarter of 2000 and involve a 10% sample of the triennial accreditation surveys during that period.

• The creation of guidelines that will permit the more specific evaluation of peer review and credentialing processes. Some of the specific issues to be examined by surveyors will include the organization’s definition of the circumstances requiring peer review; the participants included in the review process; and the timeframes in which the review must be conducted and results reported.

In addition, the Accreditation with Commendation Policy is under review by the Accreditation Committee of the Board of Commissioners. Earlier this year, the Committee discussed options for revising or eliminating the Accreditation with Commendation accreditation decision category and then sought input from the public and accredited organizations. The market research generally supported recognition of exemplary performance. However, it also reflected tolerance for a change in the current approach to recognition.

The Committee is currently considering various alternatives for recognizing outstanding organizations. The Board of Commissioners is expected to review and act on the Committee’s final recommendations in November.