ED Accreditation Update

If the Joint Commission surveyor doesn’t understand how your ED is compliant, what should you do?

You can win disagreements with surveyors — here’s how

When you have a patient in your ED who isn’t breathing, you make resuscitation a priority, and worry about patient identification later. But what happens when you have an accreditation surveyor who says you absolutely can’t give any medication to any patient without addressing patient identification?

Well, after you finish pulling out your hair . . .

One hospital administrator encountered the above scenario in her ED during a survey by the Joint Commission on Accreditation of Healthcare Organizations.

She subsequently called the Joint Commission account representative and it’s Standards Interpretation Group.

"The [Standards Interpretation Group] said it was not the intent to delay medical care in an emergency situation before having an identification number," says Julie Gresham, RN, clinical manager of nursing administration and the Joint Commission coordinator for Tulare (CA) District Healthcare System.

The Joint Commission removed that deficiency from Tulare’s report, she notes.

EDs are different

EDs have long struggled with the fact that their way of complying with standards may look different from the rest of the hospital, because EDs are different from the rest of the hospital.

The examples are numerous: nutritional screening, falls prevention, pain assessment, history and physical examinations, and pharmacy pre-review of medication orders, just to name a few, notes Bud Pate, director of clinical operations improvement at The Greeley Company, a Marblehead, MA-based consulting company that specializes in accreditation, quality improvement, medical staff credentialing, medical staff functioning, and patient flow.

"They’re all done, but they’re done differently" in the ED, he adds. "Because care is expedited, it will look different than the inpatient process."

Follow these 5 steps with surveyors

The biggest misconception among ED managers and others is that when your individualized approach isn’t recognized by the surveyor, you can’t disagree, says Joe Cappiello, BSN, MA, vice president for accreditation field operations at the Joint Commission.

"Of course you can disagree," Cappiello points out.

Pate agrees. "There’s a place and a time to do it, and a way to do it, but the biggest misconception is that what they say is gospel or that they understand your system perfectly," he says.

Consider these suggestions for a successful discussion when you disagree with a surveyor:

  • Don’t react with anger.

Make the discussion friendly, Pate suggests. Don’t disagree with a surveyor in front of other staff, he says. "Do it in a positive way, giving them mutual respect," Pate adds.

Sometimes, people’s reactions are exaggerated by the level of tension during a survey, Cappiello says. However, surveys should not be tense situations, he maintains.

"If you have done all things you should, in other words, filling out periodic performance reviews, you’re engaged in continued readiness — all the things we have talked about for years — the survey should be your chance to demonstrate compliance," he continues. "It shouldn’t be viewed as single event, test, or battle."

  • Ensure you understand the surveyor.

Make sure you understand the surveyor’s issue or request, Cappiello says.

The standards and the requirements of the Joint Commission make sense from a patient safety or efficiency standpoint, Pate explains.

"Therefore, if what the surveyor is saying doesn’t make clinical sense, you need to hang with it until you understand the clinical sense of what’s being said; otherwise, you can’t address it," he says.

Differentiate between a suggestion and a requirement for improvement, Pate advises. You can ask, "Was this a suggestion or a deviation from the standard?"

He suggests that if the surveyor says it is a deviation from the standard, and you don’t understand how that statement makes clinical sense, say, "Help me understand. What should we be doing?"

"It may become apparent that they misunderstood the process," Pate says. "Or they may understand, but they think your process doesn’t comply with the standard."

In the latter case, let them explain the logic of the standard to you, he advises.

  • Discuss — don’t debate.

"There are scenarios when people get so protective of what they’ve accomplished that any sort of criticism of that or negative reflections on that work really does cause some emotional response," Cappiello says.

That reaction leads to a back-and-forth debate of "we are in compliance" and "I don’t see it," he explains. Try to understand the surveyor’s point of view and what the surveyor is trying to identify, Cappiello suggests.

"Often, a surveyor specifies noncompliance because the surveyor can’t identify the process or forms or can’t extract compliance from staff," he adds.

If the surveyor leaves your department without the issue being resolved, there is time built into the survey schedule during which you can work with your survey coordinator to discuss the issue, Pate says.

Do your homework

However, if you reach that point, you’d better do your homework, he warns. "Ask, Exactly what standard or element of performance are we talking about?’" Pate suggests.

Then look it up in the manual. Also, go to the Joint Commission web site (www.jcaho.org) and under the "Standards" heading, look up frequently asked questions (FAQs) by clicking on "Standards FAQs — Ask a Question," he advises.

If you still disagree with the surveyor, sit down with him or her in a private meeting to discuss the situation, Pate suggests.

"There’s a fine line between waiting to be convinced and being argumentative," he points out. "Again, saying Help me understand’ is a perfect way to frame it."

  • Call the Joint Commission together.

If you are unable to resolve the issue, you and your survey coordinator can request that all of you call the Joint Commission’s Standards Interpretation Group, Cappiello suggests.

"Do it together so you can hear the same thing at the same time," he advises.

Sometimes, staff members may call the Joint Commission privately, not give a full rendering of the situation, and ask for guidance. Subsequently, they come back to the surveyor and say, "I’ve just called the Standards Interpretation Group and they say X,Y, Z.’"

"That’s not fair, because the surveyor hasn’t had a chance to share with the Standards Interpretation Group what they’ve seen on site," Cappiello says.

  • Submit clarifying evidence of standards compliance.

Finally, if there still is a recommendation for improvement in the final report and you still disagree, you can submit clarifying evidence of standards compliance electronically.

For example, the surveyor may have asked for a particular document or data that couldn’t be provided, Cappiello says.

You don’t have to send the actual document or data to the Joint Commission, he says. Instead, you can provide the date of the form, the date it was signed, or other information that would clearly demonstrate that the form was there but not obtainable.

About 50% of the recommendations for improvement that are appealed through this process are overturned, Cappiello points out.

He acknowledges that ED managers do raise the issue that their processes are not understood by surveyors.

"The other side of the coin is, we are very clear in our messages and ongoing training that there is not a single way to accomplish or come into compliance with a standard," Cappiello explains.

There are 5,000 EDs across the country that are geographically, structurally, and professionally different, and each has different compositions of staff, he notes.

"But there are general principles that guide each ED in the conduct of care," Cappiello adds. "As we think about standards, we try to develop standards that are not proscriptive, but flexible enough that these individual units can find themselves and demonstrate compliance within the standards."


For more information on how to handle disagreements with surveyors, contact:

  • Joe Cappiello, BSN, MA, Vice President, Accreditation Field Operations, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. E-mail: jcappiello@jcaho.org.
  • Julie Gresham, RN, Clinical Manager of Nursing Administration, Joint Commission Coordinator, Tulare District Healthcare System, 869 Cherry St., Tulare, CA 93274. Phone: (559) 688-0821. E-mail: jgresham@tdhs.org.
  • Bud Pate, Director, Clinical Operations Improvement, The Greeley Company, Marblehead, MA. Phone: (781) 639-8030. E-mail: bud.pate@verizon.net.