Your next survey will be customized; get ready for JCAHO’s priority focus

Data-driven survey process can work to your advantage

If you were expecting cookie-cutter questions followed by rote responses during your next survey from the Joint Commission on Accreditation of Healthcare Organizations, think again. Instead, surveyors will arrive armed with detailed information that puts a spotlight on your biggest problem areas, according to accreditation experts interviewed by Hospital Peer Review.

As of January 2004, the Joint Commission’s new priority focus process has put a new tool in surveyors’ hands, enabling them to focus on the specific issues most relevant to patient safety and quality of care at your organization.

"In our old process, we used to give surveyors all types of data on an organization, including previous recommendations, any complaints that came into our office of quality monitoring, and ORYX data. Surveyors would take all this information and, based on their own review, determine where they should focus," says Carrie Gross, manager of the Joint Commission’s division of accreditation systems integration. All the information now is obtained through an automated process, which applies a specific set of rules to determine your organization’s top four or five priority areas. "So it increases consistency in our survey process, and it also makes the surveys more specific to the organization," she explains.

The priority focus process uses your core measure data, accreditation application, previous survey results, reported events and complaints from the Joint Commission’s monitoring system, MedPar data, Medicare/Medicaid survey reports, and information from other authorities having jurisdiction.

Based on all these data, four or five of the following priority focus areas will be identified:

1. assessment and care/services;
2. communication;
3. credentialed and privileged practitioners;
4. equipment use;
5. infection control;
6. information management;
7. medication management;
8. organizational structure;
9. orientation and training;
10. rights and ethics;
11. physical environment;
12. quality improvement expertise and activity;
13. patient safety;
14. staffing.

However, if an area is identified as a priority focus for survey, it’s not always an indication that Type 1s are forthcoming, according to Christine McGreevey, RN, MS, manager of the Joint Commission’s accreditation systems integration and accreditation operations.

"It doesn’t necessarily mean anything good or bad, just that we’ll explore it a little bit more," she says. "Our hope is that we’ll be more focused on areas that could use extra help for improvement in quality care and patient safety. That is the goal."

Here are some of the ways the priority focus process will affect your next survey:

• There will be fewer surprises during surveys.

According to Michelle H. Pelling, MBA, RN, president of the Newberg, OR-based health care consulting firm The ProPell Group, what surveyors will be focusing on during your next survey shouldn’t come as a surprise, since the data they have to review are readily available to each organization. She recommends using the information to do the following:

— Identify high-volume and/or high-risk clinical service groups.

— Analyze the systems or processes in these clinical service groups.

— Analyze the systems and relevant processes for any complaints or untoward events that have been reported to the Joint Commission.

— Formulate improvements for priority issues.

Surveyors will use the available data to identify patient populations or "clinical service groups" served at your organization, categorized as cardiology, neurology, obstetrics, pediatrics, and orthopedics. Patients will be selected from high-volume groups or groups at significant risk for process failures, Pelling says. "They will then assess the priority focus areas relevant for those patients using the tracer methodology," she explains.

• Surveys will be more customized.

Instead of surveyors trying to determine compliance based solely on document review or what they observe during an actual survey, they’ll be able to assess potential strengths and weaknesses of your organization beforehand, says Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting, based in Metamora, MI. "Since the survey process is so short in terms of when they are actually on site, this will be a great help," she says.

Hospitals that fall outside what is expected or compare unfavorably to their peers are identified more easily before a survey, so surveyors can focus their efforts on addressing specific problem areas while on site, Homa-Lowry explains.

"For hospitals that have very good outcomes, it will give surveyors the ability to look at what they are doing in terms of potential best practices, and those can be shared with organizations," she adds.

• Continuous readiness is promoted.

As the Shared Visions — New Pathways process unfolds, surveyors will be able to measure and monitor hospital performance on a continuous basis in addition to triennial surveys, says Homa-Lowry. "Down the road, this will give them ongoing data about organizations for unannounced surveys and will promote a constant state of readiness. Organizations know that if the data aren’t looking good, they will have to take corrective action, and they will be held more accountable."

• Your priority focus areas are determined by patterns and trends.

Gross emphasizes that surveyors get a report only after the data are analyzed, so that trends and patterns are emphasized as opposed to individual pieces of information. "We don’t tell our surveyors exactly which pieces of data led to an area being identified as a priority focus area, because we don’t want our surveyors to get hung up on one piece of data," she says. "It’s about the preponderance of data in a certain area."

• Problem areas will be identified more easily.

It is now much easier for surveyors to identify areas where your organization falls short, Homa-Lowry advises. "The new survey process makes it easier for surveyors to validate areas of concern. For example, if an organization’s results for a specific DRG aren’t good, surveyors can target some of those patients to follow through the whole health care system." The bottom line is that surveyors know much more about your problem areas and how they’re being addressed. They know if you are targeting the areas that were identified, if the area was assessed appropriately, and if the corrective action plan has been implemented."

According to Homa-Lowry, the main two questions surveyors want answered are: "Has the organization done a good assessment of its own practices?" and "Has the organization implemented the necessary corrective actions according to the timeline submitted? If they haven’t done it, it will become quite obvious, and there will be repercussions for that," she warns.

Your periodic performance reviews amount to a contract with the Joint Commission, Homa-Lowry stresses. "You have promised to do this and will actually have to put it in place. Until now, it’s been a little easier to show good faith or show activity in certain areas."

In contrast, the new process is more objective, with surveyors focusing on three things: "Here are the data; here is what you said you were going to do; and where are the results?" she adds.

"If the results don’t show improvement, they will want to know what other corrective actions were implemented," Homa-Lowry adds.

Hopefully, your organization already will have addressed potential problems by the time an actual survey occurs, since the goal is to take corrective action on an as-needed basis, McGreevey points out. "Since the organization already has had access to the data and has been working on it, it may already have been taken care of. So things may be OK by the time we are on site. The issue is that you have to juggle your own performance improvement priorities, and surveyors do realize that."

• Anticipate surveyor requests.

Although your organization will receive a summary report identifying priority focus areas two weeks before your survey, the idea is not to use that information to learn which areas to drill staff on, Gross adds. "The new process is meant to cut down on survey preparation," she says. "The whole goal is that you don’t have to ramp up right before the survey."

However, you can use the information to facilitate complying with surveyor’s expected requests, she notes. For instance, if you anticipate that a surveyor will come in and request to do a tracer on cardiac surgery patient, be sure to have information on those patients organized by their diagnoses.

Although surveyors will have the type of patient in mind beforehand, they may not select the tracer patient at random from your list, Gross adds. They may look to you for help in selecting that patient, so it couldn’t hurt to have individual patients in mind to suggest if asked. "The surveyor will want to pick the best tracer patient they can and may ask, "Do you have a patient who entered the ED [emergency department], stayed in the hospital, and is now in a home care facility?"

• Anything is fair game.

It’s true that priority focus areas are determined before surveyors even walk in the door, but nothing is written in stone. "Based on what they find on site, they may need to change their focus," Gross says. For example, it may be that staffing was identified as a priority focus area, but instead, the surveyor discovers problems with medication management during a patient tracer. "They can choose to go off in that direction. Anything is open, and everything is fair game," she adds.

[For more information, contact:

Carrie Gross, Manager, Accreditation Systems Integration, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000. E-mail:

Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, 560 W. Sutton Road, Metamora, MI 48455. Phone: (810) 245-1535. Fax: (810) 245-1545. E-mail: or

Christine McGreevey, RN, MS, Manager, Accreditation Systems Integration/Accreditation Operations, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5000. E-mail:

Michelle H. Pelling, MBA, RN, President, The ProPell Group, P.O. Box 910, Newberg, OR 97132. Phone: (503) 538-5030. E-mail: Web:]