JCAHO to start onsite ESC validation surveys in January

Accreditation Monthly, December 6, 2005

Dear Colleague,

Predictably, the JCAHO recently announced plans to randomly conduct onsite surveys to validate evidence of standard compliance (ESC) submissions beginning in January.

Several brief items about the ESC validation surveys were posted to the JCAHO's Web site last week in its just-released October edition of This Month at the Joint Commission, an electronic newsletter.

In the items, the JCAHO reveals some details about the ESC validation surveys:

  • they will be random
  • they will be unannounced
  • surveyors will look to validate statements made in ESCs by surveying the areas that were the subject of any requirements for improvement
  • the surveys will be one day long
  • the JCAHO will not charge for the visit

We believe organizations may be able to predict when an ESC validation survey could occur: for instance, it would make sense for JCAHO to target the period of time shortly after the JCAHO accepts ESCs, or shortly after submitting measures of success for accepted ESCs.

This announcement reinforces the need for organizations to treat continuous readiness and JCAHO accreditation seriously and with integrity. Gone are the days when the central office at JCAHO would merely accept written action plans created in response to Type 1 findings cited during a scheduled triennial survey without validating that the action plan was actually carried out and improvements sustained. Under the new paradigm, organizations undergoing an unannounced triennial or for-cause survey need to first confirm the validity of each requirement for improvement (RFI), fix the problem if a legitimate problem exists, and sustain the execution of that fix.

Why did I make a point of suggesting that organizations first determine that the surveyor's finding was valid and legitimate? Because surveyors make mistakes and it is essential that organizations seek to clarify (refute) erroneous findings prior to the conclusion of the survey or at the very least in the week or two immediately following the survey. After all, it is impossible to fix something that is not broken, and this adage applies to any finding that is (1) miscategorized by the surveyor (e.g., citing a deficiency in performance incorrectly under an "A" element of performance (EP) rather than correctly under a "C" EP) or (2) circumstances in which the surveyor has overlooked evidence that the standard is met (e.g., they have not studied a sufficient sample size to draw a valid conclusion).

As an example of surveyor miscategorization of a finding, I have been called in to consult with a hospital that received a finding under PC.2.120, EP 2 when the surveyor found an inpatient record missing an H&P within 24 hours of admission. PC.2.120 EP2 is an "A" EP, yet clearly the surveyor cited a performance defect by the fact that an H&P was missing from the record. Indeed, there was nothing wrong with the rules and regulations or policies and procedures governing the timeliness of H&Ps at the hospital.

So, the surveyor made an error citing the observed performance flaw under this standard and EP. If left to stand, how on earth will this hospital create an acceptable Evidence of Standard Compliance (ESC)? Neither the rule and regulation or policy and procedure are broken! In fact, in this case the rules were written perfectly.

Instead, I am assisting the organization make the case that the finding should have been made under PC.2.130, EP 2 which is a "C" EP with a Measure of Success (MOS). When JCAHO agrees to recategorize the finding under PC.2.130 EP 2, we will simply conduct an audit using the JCAHO rules for submitting a clarification audit of a "C" EP and I am certain the findings will be removed. Thus this hospital will not be placed in the untenable position of fixing something that was not and is not broken.


John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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