Accreditation

'Disaster plan' helps staff prep for unannounced survey

Briefings on Accreditation and Quality, August 1, 2005

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Survey tracker

'Disaster plan' helps staff prep for unannounced survey

Learning objectives: After reading this article, you will be able to

1. identify the JCAHO's focus areas for survey

2. list the necessary steps to take when a surveyor arrives unannounced

3. discuss ways to prepare staff for unannounced surveys

Having a strategy similar to a disaster plan will help your organization prepare for an unannounced survey, which will be critical when the JCAHO moves to the unannounced format in 2006.

Providence Saint Joseph Medical Center in Burbank, CA, had a random unannounced survey nearly two years ago, and as a result, the 498-bed hospital revamped its survey preparation activities to ease the initial chaos that may result when a surveyor arrives unexpectedly, says Sue Kohl, RN, the hospital's director of risk management and regulatory compliance and patient safety officer.

The hospital tested its plan in late spring, and the results were impressive.

"Amazingly, it worked beautifully," Kohl says. "[An unannounced survey] tends to put an organization into momentary chaos, wondering what [surveyors] are going to look at, what they are going to need."

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

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