Prepare for late-night Joint Commission surveys

Are you ready for a "sneak attack" from the Joint Commission on Accreditation of Healthcare Organizations? Surveyors often enter the hospital for night surveys through the ED since the doors are always open, warns Kathleen Catalano, RN, JD, director of administrative projects at Children’s Medical Center of Dallas.

In one hospital, the surveyors arrived at 3 a.m. on the third night of a four-day survey, she notes. "However, in most cases, they arrive in the evening of day two for a four-day survey, day one of a three-day survey, etc.," she adds. Usually if a survey is taking place, management is present and can lead the visitors through the areas, notes Catalano. "Staff on nights and evenings are generally not accustomed to outsiders inspecting," she says. "Also, the ED is usually hectic at that point in time. If staff are not prepared for the visit or how to approach and talk with a surveyor, problems can arise."

Here are ways to prepare for a night survey:

Make sure night shift’s answers to questions are the same as the day shift.

When surveyors ask questions on the evening or night shifts, the answers should be the same, says Patrice L. Spath, RHIT, a health care quality specialist with Brown-Spath and Associates, a Forest Grove, OR-based firm that provides performance improvement training for health care organizations. (See "Here are sample surveyor questions," in this issue.) Answer according to what your policy/procedure is, stresses Spath. "Don’t answer according to the way you usually do it, if what you usually do is a bit different from what is written down in the policies/procedures," she explains.

Provide staff with consistent training.

Staff nurses who work evening or night shift should receive the same pre-survey training as day shift staff, says Spath. "Nurses may be reluctant to come in during the days for training," Spath adds. "That’s why innovative training techniques must be used, such as poster presentations and puzzles or brain teasers."

Surveyors want to see consistency between the answers given by day shift staff and the answers provided by staff on other shifts, Spath says. "For example, [they may ask] How do you exchange clinical information with providers when patients are transferred out of the ED to another hospital?’ The process should be the same regardless of the time of day," she explains.

The surveyors don’t want management present, says Catalano. "They feel that a hospital should be able to handle operations without the management team, since that is the normal practice on evenings and nights," she explains. There should be consistent teaching hospitalwide for age-specific competency, sedation, performance improvement, safety, medical equipment, utilities management, security, hazardous materials and waste, infection control, pain management, restraint, and seclusion, says Catalano. "The entire staff must be able to answer housewide questions," she adds.

Ensure consistency of care.

When observing, surveyors will be looking for differences in practices from the day shift, says Spath. "For example, are infection control practices the same at night as they are during the day? Are leftover food trays sitting out on the nurses’ desk from supper? Are dirty linens handled in the same manner?" she asks. Surveyors will look for evidence of typical problems that occur in the ED on evening and night shifts, says Spath. "For example, it is common for ED staff to have trouble getting in touch with patients’ private physicians or obtaining a specialty consultation in the late evening or at night," she says.

Patients must be provided the same level of care 24 hours a day, says Spath. She suggests asking evening and night shift nurses if there are any areas where patient care might differ significantly from the practices during the day. "Focus on access to services and continuity of care, such as admissions and transfers," she advises. "If evening and night shift practices are not consistent with the written policies and procedures of the organization, you need to fix this problem before your next survey."

Spath provides this example of a common continuity-of-care issue in the evening: An elderly woman is ready to leave the ED after having been treated for acute gastroenteritis and dehydration. During the day, there is someone at her assisted living center that can come and pick her up. At night, no one is on duty who can transport her back. Staff in the evening and nights should follow clearly defined policies/procedures for those problematic scenarios, says Spath.

Ensure adequate staffing.

Surveyors will want to see that the ED is adequately staffed during off-hours, says Catalano. "They tend to split up," she explains. "One may go to the staffing office and have the coordinator pull the staffing for recent holidays and compare that with present staffing. They will also want to see the master staffing plan."


For more information on evening and night accreditation surveys, contact:

Kathleen Catalano, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-8722. Fax (214) 456-6081. E-mail:

Patrice L. Spath, RHIT, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116-0721. Telephone: (503) 357-9185. Fax: (503) 357-9267. E-mail: Web: