How to prepare for a JCAHO survey

Communication, well-prepared staff are crucial

Although questions have been raised about the relevance of hospice accreditation from the Joint Commission on Accred itation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, clearly the program is growing and isn't likely to go away soon. (For more information, see cover story in this issue.)

While the hospice industry works collectively to make JCAHO standards more hospice-specific, there are many reasons an individual provider might choose to become accredited.

These include the requirement for hospice programs whose parent corporations are accredited to also become accredited, a desire to qualify for managed care contracts, pursuit of a competitive advantage and marketing edge in a community, and a corporate commitment to performance improvement.

Following are tips and recommendations from hospices that have gone through the process on how to prepare for a successful accreditation survey.

"When we first got the manual, my vice president of clinical services and I very quickly skimmed through it. Our first impression was,'This is going to be easy. We do all of this stuff. No problem.' Then we got deeper into it," says Karen Nichols, BSN, CEO of Valley Hospice in Steuben ville, OH. "The first time you read through it, probably two or three areas will jump out at you as areas you'll need to work on. For us, it was staff competencies and environmental safety and disaster planning."

Nichols presented her "secrets" for passing accreditation in a workshop at the National Hospice Organization management meeting in St. Louis in June. For her agency, the process began with dividing up the manual and assigning its 11 chapters to the relevant managers, asking them to review the requirements and comment on whether the agency was meeting them, or if not, what they could recommend to bring it into compliance.

"We set aside a whole day for all eight managers to come together, and we went through the manual standard by standard by standard. It was probably the most tedious day I've ever spent, but I think it was worth it, because we kept notes and at the end of the day we had a work plan that we could copy" and distribute to all staff, Nichols relates. "I also felt it was important for all of the management team to be aware of what needed to be done and what everybody was doing." Other recommendations include the following:

1. Involve the entire agency, says Kathy Coffee, MS, RN, CS, administrator of Good Samaritan Hospice in Babylon, NY. "We incorporated people in the agency at the grass-roots level in all of the changes. We spent a full year, started from scratch, looked at each standard, and people loved it. Every one of our staff of 40 was involved. I wanted them to be comfortable with the terminology, and it was an opportunity for people to learn something new."

2. Good communication is crucial through- out the preparation process, Nichols asserts. "We always try hard to communicate through monthly staff meetings, updates and memos. But it's especially important when getting ready for a JCAHO survey, because there's so much information that everybody has to have." Nichols' agency planned 15-minute inservices on each chapter in the JCAHO home care manual and presented them to staff after the weekly team meeting for 11 straight weeks. Staff were given written information on each chapter being presented, and a three-ring binder to hold this material, for future reference.

3. A well-prepared staff is the goal of the preparation process, so they can answer questions about the agency and its policies when the JCAHO surveyor comes calling. It's important not to make staff feel paranoid, to keep them interested in the process, and to recognize when they need a break, Nichols says.

"We promised staff we would not make them jump through hoops, that we would carefully think through any [policy] change that we made so it wouldn't seem ridiculous to them, and that we would solicit their input and feedback," she adds. Staff also played a JCAHO trivia contest, with prizes for individuals and teams with the most right answers.

4. Involve other key parties. Accreditation surveyors may ask to interview board members, volunteers, and representatives of other agencies with which the hospice contracts, including nursing homes, pharmacies, and other contract vendors. These other parties also need ongoing information about the accreditation process and how the hospice is going about fulfilling its requirements so they will be well-versed in the key issues when the surveyor arrives. The hospice medical director also should play a key role in preparing for accreditation and being available to the surveyor.

5. Take advantage of available resources, including manuals and other materials published by JCAHO, newsletters, and the services of accreditation consultants who can work with the agency on areas that are out of compliance. Do mock surveys to test the agency's readiness. Attending JCAHO accreditation workshops also is recommended.

6. Get into the habit of auditing charts early on, and use this as a way to test how far along the agency is in meeting the requirements.

7. Make survey preparation an ongoing, daily commitment, built into the organization's routine functioning, rather than trying to cram for the survey. It may take a full year to get ready for an accreditation survey, but this kind of systematic preparation can be invaluable. Also, find ways to streamline audits and education into an overall quality and performance improvement process.

8. Good organization during the actual survey is also essential. The easier the hospice can make the surveyor's job, such as presenting information in a clear, easy-to-read format, the better the process is likely to go, Nichols says. Instead of presenting their surveyor with 75 pharmacy contracts, the hospice provided one sample contract and a list of contract pharmacies, with an offer to make any others available, if desired. "You also need to remind your staff to stay focused. Remind them that the surveyor is there for a reason." Protecting confidentiality of patient information is an often-overlooked issue, and worth reiterating at survey time, she adds.