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How to track down safety deficiencies in anticipation of an unannounced survey

Accreditation Connection, January 23, 2006

Safety officers should devote attention to training staff throughout the hospital about this substantial shift in the JCAHO's survey process, says Steven MacArthur, safety consultant with The Greeley Company, a division of HCPro, Inc. While staff education should include standard safety items, pay particular attention to recognizing hazardous or deficient safety conditions.

Although overall your hospital may have quality programs in place with good documentation, little problems can still trip you up, When all of these small concerns come together during an unannounced survey, they can add up to a requirement for improvement from the JCAHO, says MacArthur.

During a survey, "one surveyor might find a utility closet with a family of dust bunnies, then another finds a dorm-type refrigerator [that] hasn't been dragged out and cleaned beneath for a while, and then they find a dirty mop head in a behind-the-wall space in the operating room area," says MacArthur.

"And together, [these problems] could end up as a finding under infection control," he says.

Or "an out-of-date fire extinguisher here, a penetration there, some storage in a stairwell over there, and you have a life-safety management finding," he adds.

Hospitals still struggle with being in a continuous, ever-ready state. Nevertheless, that stance has to become a way of life with the unannounced JCAHO visits, says Yvonne Wojcicki, MS, MT(ASCP), safety officer at St. Vincent's Hospital in New York City.

"We're doing our own tracers and trying to keep awareness high through more interaction with staff," Wojcicki says.

The key to success will be to have many sets of educated eyes on the lookout for deficient conditions. Larger hospitals may be at a distinct disadvantage in this respect because there's so much more space to watch, more opportunities to get into trouble, and chances are, more surveyors poking into dark corners, he says.

The more you allow frontline staff to keep their eyes on things, the more successful the hospital will be during unannounced visits from the JCAHO.

Adapted from the January issue of Briefings on Hospital Safety.

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