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Is there a good way to disagree with a surveyor’s finding?

Accreditation Connection, September 17, 2004

If you disagree with a surveyor's finding, call the JCAHO immediately to contest it, advises one California accreditation coordinator who didn't want to wait for the JCAHO's formal appeals process.

A surveyor cited Tulare (CA) District Healthcare Systems with a recommendation for improvement during its April survey after noticing that ED employees did not identify a patient before administering medications, says Julie Gresham, RN, JCAHO coordinator.

As you know, National Patient Safety Goal #1 requires clinicians to use at least two patient identifiers when administering medications or blood products. The hospital questioned whether the surveyor's interpretation of the goal was too narrow when applied to a critical care patient in the ED.

Head's up: On January 1, 2005, the JCAHO's patient identification requirements will expand to include "other specimens for clinical testing" and "other treatments or procedures."

At Tulare, staff apply a patient-identification band and register patients within five minutes of their arrival. The surveyor noticed that staff did not do this for at least one patient who presented to the ED in need of urgent care, and that staff administered medications before properly identifying the patient because time was critical, says Gresham. "You're talking about a patient who was not breathing," she says.

Despite the emergency situation, the surveyor stood firm that the facility must comply with the patient safety goal. "She was very cut and dry," Gresham says. Gresham contacted her JCAHO account representative immediately after the survey to state her objections to the surveyor's finding. She argued that such a narrow interpretation of the goal could jeopardize patient safety during emergency situations.

Her persistence paid off: The JCAHO removed this recommendation for improvement, says Gresham. She advises others who object to a surveyor's findings to call the JCAHO immediately and provide clear explanations about what went wrong. "We didn't wait to do a written response," she says.

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