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Preparing for a Joint Commission survey is not something that can happen overnight, warns Ann Kobs, MS, RN, former director of the department of standards at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL. "This is supposed to be a way of life, and to have teams that have never met until immediately before the survey is no way to do business.
"The care of a patient requires a multidisciplinary approach at all times, which means that various departments must talk to one another," says Kobs, who now serves as president of Type One Solutions in Fort Myers, FL. "Getting ready means being ready every day and making sure you are taking care of your patient’s rights every day."
Regina Walczak, director of organizational performance at Saddleback Memorial Medical Center in Laguna Hills, CA, agrees that trying to accomplish too much just before a JCAHO survey spells trouble. But she also argues that numerous steps can be taken immediately prior to a survey as well as during the survey to facilitate a successful outcome.
In fact, Walczak, a former surveyor herself, lists a range of measures that her facility recently employed that helped bring about a very successful survey outcome.
For starters, Walczak says there are important logistical "dos and don’ts" that hospitals should keep in mind prior to a survey, such as convenient parking and making sure surveyors have a comfortable, private workroom that includes food and beverages and outlets for their computers. "First impressions are always important," she explains. "Having parking spaces for them and having people direct where they go all help send a signal that you are ready for this process."
Walczak says her staff also made sure that every surveyor had an escort who accompanied him or her at all times throughout the survey. She says that person’s sole responsibility was to take notes regarding any recommendations surveyors made. At the end of the day, those comments were transcribed, and staff reviewed them early the following day.
Susan Goodwin, a consultant with the Hospital Company in Nashville, TN, says that staff escorts, functional team leaders, and managers who participated in the survey process should always conduct a debriefing. She adds that debriefing with staff should take place the night before as well as the following morning.
If any Type 1 recommendations come out of the survey, the hospital will receive notice of that in its final report from JCAHO, she notes. "They get a heads up about that from the surveyors on the last day of survey, and the written progress report is what the hospital has to send back to [JCAHO] to show that they have corrected the problem," she says. (See list of 1999’s most common Type 1 recommendation.)
Joint Commission Surveys’ Top 10 Trouble Spots for 1999
|The charts listed below show the top ten problematic standards in four health care settings that received the most scores of 3, 4, or 5 for surveys conducted in 1999, according to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.|
Walczak reports that once the surveyors left, her staff immediately convened and passed out copies for all the key managers and directors so they could review the recommendations and determine whether there was anything that needed to be corrected immediately.
"That was very helpful," she says. "If there were any agenda changes that required changing assignments, they could take that agenda and make the revisions and get copies out to everyone as assigned."
Walczak says her hospital also staffed a "war room" accessible via wireless phones placed throughout the hospital, so that anytime a surveyor made a request it could be met immediately. The first rule was that no phone went unanswered. Whenever surveyors had a request, runners could immediately respond.
In addition, scribes would bring down their notes, and someone in the war room would be assigned to type the findings and have them finished by the end of the day.
"Hospitals are dynamic places," Walczak cautions. That means hospitals should have people scanning the halls to make sure things don’t end up in the hallways. In fact, Walczak says, hospitals should have somebody almost one step ahead of the surveyor at all times to make sure items are on the right side of the hall, rooms are clean and locked, and logs are complete. "Those are things you can do until the minute before the team shows up on the floor," she explains.
She notes that one time a surveyor was in the OB/GYN area. An anesthesiologist had left an anesthesia cart in the hallway while finishing up with a patient. "It turned out to be on the wrong side of the hall," she reports. "The surveyor simultaneously turned the corner, and we got dinged."
Walczak adds that opening remarks are very important in terms of setting the tone of the survey. She says hospitals should try to "sensitize" surveyors about certain issues. For example, she says, her facility treats an aging geriatric population where the average patient age is about 80 years old. The hospital also faces a challenge in terms of capacity, she reports.
"We are filled to the gills and, at times, we have patients who are brought in and they sometimes have to wait for a bed," she says. "Those are things you want to share with them so they know it is an issue you are grappling with and not something that you are trying to hide."
Finally, Walczak stresses that it is important to keep in mind that once the surveyors walk through the door, they are in charge. "A lot of hospitals try to fight that and instead try to create their own agenda." But she says surveyors may see that as a diversionary tactic.
"Surveyors see through those things in a heartbeat," asserts Walczak. "It is not a bad thing to showcase other areas as long as you do it in the background and don’t try to devote survey time."
Goodwin also notes that JCAHO requires public notification prior to the survey. Hospitals are required to post notice in the newspaper as well as on a publicly accessible bulletin board within the hospital. "That is something that some hospitals forget to do, and they end up with a Type 1 recommendation based on that technicality," she warns. "Public notice has to be posted 30 days prior to survey."