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Ask medical leaders to attend JCAHO prep meetings

Accreditation Connection, May 3, 2004

The JCAHO has long expected your physicians to participate in the survey process. However, that expectation became a full-blown requirement with the introduction of the JCAHO's Shared Visions-New PathwaysTM initiative.

Surveyors will ask physicians about patient safety, restraint use, pain management, credentialing, and other medical staff issues. In addition, the JCAHO is interested in learning more about "physician priorities and strategies for improving the quality and safety of care provided to their patients."

Find out what strategies your colleagues employ to prepare their physicians and medical staff leaders for JCAHO visits in 2004.

Education essentials

New York City-based North General Hospital is well prepared for the JCAHO's increased scrutiny of physician participation: The hospital begins preparing medical staff leadership approximately eight months prior to its surveys.

Specifically, North General holds 90-minute medical staff leadership JCAHO prep meetings twice a month, according to Nilda Conrad, MSB, CMSC, CPCS, assistant vice president of med-surgical and professional affairs.

All medical staff leaders are encouraged to attend these meetings, and meeting minutes and attendance are documented.

Each leader is given a book, prepared by the medical staff office, which lists all JCAHO standards that affect the medical staff and patient care. The leaders are required to bring these books with them to each meeting so they can insert the various handouts distributed during the sessions.

Department chairs, directors, and committee chairs are invited to the meetings to discuss the standards that affect their area of responsibility or expertise.

These leaders review the standards, discuss how the department or committee complies with the standards, and explain how members of the department or committee should respond to JCAHO surveyors' questions regarding compliance issues.

According to Conrad, the following topics are discussed at the JCAHO survey prep education sessions:

• Infection control(IC): Practices and procedures 
• Health information management: Legibility, incomplete charts, requirements, and documentation
• Quality management: Performance improvement (PI) activities and requirements (in addition, the leaders in attendance are asked to make short presentations regarding their department's PI activities).
• Research: Institutional review board and research activities and requirements
• Nursing: Tracer methodology, restraints, patient and family education, patient relations, continuum of care, and interdisciplinary plan of care
• Environment of care: Falls, incidents, hazardous materials, fire drills requirements, etc.
• Emergency management: Incident command, drills, disaster preparations, hospital's management plan
• Nutritional services: TPN, nutritional screens
• Risk management: Incidents, reporting requirements, root cause analysis, etc.
• Administration: Governance, leadership issues and standards
• Operating room: Moderate sedation policy, wrong site/side policy, time-out procedures, etc.

"We also go over sample questions with regard to leadership issues and PI," Conrad explains.

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