Unannounced surveys: What you’ll need to do within minutes of JCAHO’s arrival

Be ready when the surveyors step foot in your organization

It’s the moment of truth: After months of preparation, inservices, and mock patient tracers, you finally get the phone call: Surveyors from the Joint Commission have arrived at your hospital.

All JCAHO surveys will be unannounced as of Jan. 1, 2006, and this is at the top of any quality manager’s worry list these days. "There is no downtime anymore," says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Healthcare in Charlotte, NC.

"You need to prepare logistically and think through what an unannounced survey means to your organization, so you are ready when the surveyors step foot in your hospital," she explains.

Presbyterian Healthcare volunteered to pilot test the unannounced survey process, to occur sometime this year.

What you do in the first few minutes after surveyors arrive will affect how smoothly things go thereafter. "A well thought-out plan is equally as important as staff preparedness," says Missi Halvorsen, RN, BSN, senior consultant for JCAHO/regulatory accreditation at Baptist Health in Jacksonville, FL.

When Baptist Health underwent an unannounced special issue survey last year, it got a chance to put its processes to the test. "We had a practice run-through," she notes. "We learned that the continuous preparedness processes we had already put into place worked very effectively at a moment’s notice."

Draw upon disaster planning

Utilize the same principles in your hospital’s disaster plan to formulate an effective approach for unannounced surveys, recommends Catherine M. Fay, RN, director of performance improvement at Paradise Valley Hospital in National City, CA.

"When the surveyors arrive, it will be necessary to assemble many resources from the management team to disseminate information and put plans into action," she explains. "Your existing disaster plan can be scaled down to meet specific needs for on-the-spot survey preparation."

This will eliminate the need to start from scratch in developing a method for managing unannounced surveys, Fay notes.

For the off-hours when administration and the leadership team aren’t present, the process can be adapted mirroring the way a disaster plan is modified, she adds.

Establish a command center as with disaster planning to effectively manage the survey with an organizationwide focus, Fay says. "You may want to establish the center in a location different from the surveyors’ base."

Personnel manning the center should be members of the hospital leadership team who don’t have direct responsibility for patient care services, she continues. "Managers and directors for patient care services will be most effective by remaining in their areas to oversee their department’s preparation and to receive instructions and information about the survey."

Presbyterian Healthcare used the communication system developed during disaster planning as a model to notify staff about an unannounced survey.

"We are very active in our disaster preparedness and do disaster drills twice a year, so we used the same structure," Swain points out.

Repeatedly practicing the survey notification process actually improved the organization’s disaster notification process, she reports.

"We have now tested our emergency notification text paging process many times during our mock surveys, and it has gotten better every time," Swain adds. "So when we do have a disaster, we now have a really accurate list."

Although there is tremendous focus on JCAHO unannounced surveys, the systems you develop can be used for other types of unscheduled surveys as well, Fay says.

"Department of Health, CMS [the Centers for Medicare & Medicaid], and EMTALA [the Emergency Medical Treatment and Labor Act] surveyors could arrive unannounced as well — so it is important to prepare in the same way for all these possibilities," she adds.

At Gwinnett Medical Center in Lawrenceville, GA, preparations for unannounced JCAHO surveys were tested during a CMS validation survey. "Any type of unannounced survey benefits from this type of coordination," explains Wendy H. Solberg, CHE, director of quality resources.

"Essentially, you need a plan to coordinate multiple surveyors in your system in a flash. Within 30 minutes of the CMS validation surveyors arriving, we had some of them on their way to points throughout our system with a guide. The initial thought is daunting — but it falls into place with this type of planning," she adds.

Here is a step-by-step process for what will occur during the first few hours of an unannounced JCAHO survey, with recommendations to improve preparedness:

1. Escort the survey team to administration.

The very first step is for someone to bring the survey team from the front door of the hospital to the administrative offices, Swain notes.

"We will activate our policy on external surveyors and have trained staff to bring surveyors to the administration area," she says.

The policy stipulates that no manager will undergo a survey alone. "We support all types of surveys and expect all staff to notify administration and my office that a survey is about to begin," says Swain.

Surveyors may feel comfortable bypassing the information desks in the hospital entryways, especially if they’re familiar with the hospital.

"If that occurs, staff still have to call our office," Swain notes. "We then join in the survey, assess the credentials of the surveyor, and arrange to have the appropriate people surround the surveyor and support the process."

Training of all management staff is done routinely as the policy is revised, she says. "Also, because we are surveyed frequently by so many agencies, we have the opportunity to reinforce the training as surveys occur."

Immediately after surveyors arrive, a telephone list will be activated by the administrative assistant, and everything will be put into motion. The surveyors will be brought to a videoconferencing area for an orientation with the two other hospitals in the network that will be surveyed at the same time. "We’ve got between 8 a.m. and 9 a.m. to get them settled and our orientation process done," Swain says.

Be on alert for impostors

Recently, JCAHO notified organizations that impostors posing as surveyors have shown up in several hospitals and were stopped by staff as they tried to get access to a floor. The matter currently is being investigated as a federal offense.

"Surveyors should go to administration first and shouldn’t be going directly to the floors, so that in itself should make you suspicious," says Halvorsen.

"They will show you a letter and ID badge and inform you how many surveyors there are and how many days they’ll be there." To be on the safe side, you should contact your JCAHO representative to verify that surveyors are scheduled to be on your campus, she suggests.

2. Alert staff that surveyors are on-site.

As soon as you hear surveyors are present, that’s when your notification plan should go full speed ahead. "I sent out an e-mail to our leadership and employees," Halvorsen notes. "Draft that e-mail ahead of time, so all you have to do is sit at your desk and hit send.’ The word spreads very fast at that point."

Some organizations make announcements with overhead pages using codes such as "Dr. Jayco," but it’s better to be up front, she points out.

"I told our organization to announce Baptist Health welcomes the Joint Commission’ several times during the day. That lets your people know there are surveyors here, and welcomes them at the same time, instead of being secretive about it," Halvorsen adds. "They understand that we have to let everyone know they’re on campus, and that’s fine."

The first step is to list who in the organization will be notified and how, including directors and department managers up to vice presidents and senior leadership, Swain notes.

First, a mass e-mail is sent out stating that JCAHO is in the facility, providing a "heads-up" for staff. The next e-mail sent covers everyone on the organization’s "Emergency Notification" list, stored in Microsoft Outlook, advising managers where to meet and at what time. The third notification is sent out from the command center.

"As the survey progresses, the command center is activated and all staff who will be in roles of escort, support, and review are notified via the command center communication process," she adds.

During mock surveys, it became apparent that many people who thought they were on the list of contacts actually weren’t, so they were added, Swain says.

"We also found that our paging company was slow and had some problems, and found dead spots in the house, so there were lots of reasons why people weren’t getting their pages," she points out. "Some pagers were found to be old and inadequate, and others did not support text paging and had to be changed out."

When surveyors arrive unannounced at Gwinnett Hospital System, the chief operating officer and the director of quality resources are notified immediately.

"We then enact our command center, which is very similar to our disaster processes," Solberg notes. "In a nutshell, we have a pager listing and a group page is dispatched along with an e-mail, letting everyone know that we have company."

The command center then will coordinate all communications between staff and the appropriate key individuals. "We will also distribute cellular telephones to facilitate communication during the survey," she says.

3. Show surveyors to their designated workspace.

In addition to designating a command center for staff, you’ll also need to prepare a room for the surveyors to work out of, to facilitate review of medical records, policies, and personnel files.

"We use our boardroom, but a classroom or meeting room would also work," Swain says.

Key members of your organization’s leadership team representing functions that cross most hospital services, including safety officer, human resources director, performance improvement coordinator, environmental services director, director of infection control, director of medical staff services, and chief of the medical staff, should join administration and the JCAHO coordinator in the area you designate for the surveyors’ opening conference, Fay says.

4. Anticipate the surveyors’ requests for documentation.

The first thing surveyors will want is an up-to-date census listing of patients by diagnosis, since they will need this information to select which patients will be traced.

To avoid problems, get in the habit of pulling an active daily census listing when you pick patients to trace during your mock surveys, Halvorsen recommends. "It’s nice to periodically check the accuracy of your list, instead of just going to the floor and pulling a chart," she says.

Update your policies and procedures

You should be updating your policies and procedures on an ongoing basis and have these available upon request, Halvorsen notes.

"There isn’t a document review session anymore, but they do spend quite a bit of time in the survey preparation meeting asking for documentation and looking at things," she adds.

Halvorsen still prepares the traditional document review notebook for the different chapters of the standards, and these are kept updated.

"So when the surveyors come, all I have to do is access those notebooks with no running around. The last thing I want to do is hand over my entire policy and procedure manual — that’s like giving them candy," she says. "My notebooks are designed to have the documents that they normally request to see, and that’s all."

Similarly, you should keep action plans for your periodic performance review in a separate folder, Swain advises.

"The surveyors already have access to other information about us, and we don’t really want them to have our action plans since that is private information," she explains.

5. Mobilize all the people who will be escorting surveyors.

These individuals will need to pick up walkie-talkies or cell phones for direct communication to the command center, Swain continues.

The number of people involved depends on the size of your organization, she adds. "We have seven surveyors for five days, so there are a lot of logistics involved, but if you have three surveyors for only three days, you can scale that down."

Additional support people may or may not stay with the surveyor the entire time but can be used as backup if the designated escort person isn’t available for any reason, Swain notes.

As an incident commander, you need to stay in constant contact with the command center to avoid losing track of the surveyors, she says. The organization uses cell phones, walkie-talkies, text paging, wireless computers, and telephones to facilitate communication during surveys.

"Tracers take surveyors in every direction. This is a major consideration when the interesting patients are those coming through the ED, then going to the OR and the cath lab," Swain adds. "You can go to the bathroom, and literally you don’t know where your surveyors went, because they just take off."

The organization used to pair its JCAHO team leaders with the surveyors, but this was changed recently, Swain says.

"The team leaders may be directors or managers who need to be in the areas being pummeled with tracer interviews," she explains. "We now use surveillance people from infection control, medical resource management, quality outcomes, and folks working with core measure analysis in the support person role."

Vice presidents and directors of services, who have many managers to cover the departments, are used as the actual escorts for surveyors.

"Even at that, we must provide for multiple changes of escorts due to the duration of the survey," Swain says.

Swain remains with the surveyors in their workroom, while the organization’s regional standards manager acts as the incident commander at the command center and the administrative assistant in charge of computer notifications, updates, and videoconferencing.

"Each of us can roll up into the other positions,"she adds. "However, we use administration’s executive assistants to man the computer, should one of us be gone."

The chapter leaders of Baptist Health’s systemwide accreditation committee were designated "survey ambassadors," as the main contact people accompanying surveyors.

These individuals should have expertise with the surveyor’s area of focus, Halvorsen says, such as pairing a medical staff member with the physician surveyor and a nurse leader with the nurse surveyor. "For example, the team leader I pulled in for the infection control issue was our infection control nurse, because she knows those standards and I knew she would be the best person," she says.

A scribe should be used to support the ambassador by recording information for future surveys and making notes on follow-up or policies requested, Halvorsen says.

Runners can act as scouts to alert departments that surveyors are on their way, either in person or with a phone call.

"Surveyors don’t know where they’re going — they don’t have a map. Since they have to rely on you to get them there, you can send the runner ahead," Halvorsen says.

Runners also can obtain a policy or person as needed or make sure that a conference room is ready before surveyors arrive.

"These three positions can alternate as needed," she adds. "As long as they have that knowledge base about the standards, they can swap roles."

Have two backups just in case the primary support person isn’t available, Halvorsen recommends. "If I am not here, I have two other people on my team who can function in my role," she says. "We try to stack our support three deep."

It’s true that surveyors don’t want an entourage controlling their every move, but they will expect to have escorts, Halvorsen notes.

"I try not to intimidate the surveyor with too many people, but you know what? It’s our survey, and it’s our campus," she says. "Give them plenty of opportunity to interact with staff and don’t interfere with that. It’s not our role to impede that process — we are there to facilitate it. But we are also there to help staff if they don’t understand what the surveyor is asking or help smooth things over a little bit."

Your escort system also can be used for state reviews, behavioral health or transitional care certification, or county health department inspections, Swain adds.

"We don’t do this only for the JCAHO. We don’t leave any surveyor to their own devices; they always have a group of us with them," she says.

[For more information on preparing for unannounced surveys, contact:

  • Catherine M. Fay, RN, Director, Performance Improvement, Paradise Valley Hospital, 2400 E. Fourth St., National City, CA 91950. Phone: (619) 470-4263. Fax: (619) 470-4162. E-mail: FayCM@ah.org.
  • Missi Halvorsen, RN, BSN, Senior Consultant, JCAHO/Regulatory Accreditation, Baptist Health, 1325 San Marco Blvd. Suite 601, Jacksonville, FL 32207. Phone: (904) 202-4966. Fax: (904) 202-4920. E-mail: Mary.Halvorsen@bmcjax.com.
  • Wendy H. Solberg, CHE, Director, Quality Resources, Gwinnett Hospital System, 1000 Medical Center Blvd, Lawrenceville, GA 30045. Phone: (678) 442-3439. Fax: (770) 682-2247. E-mail: wsolberg@ghsnet.org.
  • Paula Swain, MSN, CPHQ, FNAHQ, Director, Clinical and Regulatory Review, Presbyterian Healthcare, 200 Hawthorne Lane, Charlotte, NC 28204. Phone: (704) 384-8856. E-mail: psswain@novanthealth.org.]