Accreditation

Protect against imposter surveyors

Briefings on The Joint Commission, June 1, 2005

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Recent mainstream media news stories and a bulletin from the U.S. Department of Homeland Security about people posing as JCAHO surveyors and trying to gain access to hospitals nationwide means your hospital's leadership may soon call on you for information and guidance.

Steven MacArthur, safety consultant for The Greeley Company, a division of HCPro, Inc., which publishes this newsletter, says that from what he can tell after studying the cases, each event was managed in an appropriate fashion by the individual organizations.

But be prepared to answer questions about how your facility would handle a phony JCAHO surveyor.

Unannounced isn't unfamiliar

Most, if not all, hospitals have already experienced unannounced visits from regulators, such as an official from the department of public health, MacArthur points out. And JCAHO-accredited hospitals are preparing for all surveys to be unannounced in 2006. So there already are--or should be--processes in place at your facility to manage these types of events, he says.

"Most organizations recognize that there are those who would try to circumvent security systems and thus are attentive to them," MacArthur says. "You may have to inconvenience someone somewhere while you find out if they're for real or not, and by that point, if they are imposters, they'll probably already have skedaddled."

Since 9/11, hospitals have looked at interlopers more critically, MacArthur says. The recent string of imposter surveyor incidents means that it's necessary to stay vigilant.

Consider revisiting your processes for admitting regulators, and extend that evaluation to how your facility handles vendors, contractors, and others, MacArthur suggests. Do this by performing a risk assessment of the associated practices and identifying strategies that best preserve security for your organization.

Don't be concerned about inconveniencing a surveyor for a few minutes because you want to be diligent in your management of such events, he adds.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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