Accreditation

First unannounced JCAHO survey catches AZ medical center by surprise

Briefings on The Joint Commission, April 1, 2006

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Editor's note: This story is the first in an ongoing series about the experiences of facilities that have undergone unannounced JCAHO surveys this year.

Performance Improvement Coordinator Eileen Pressler, RN, had been expecting JCAHO surveyors to show up unannounced at her hospital's door no earlier than February, based on the fact that her hospital was due for its triennial survey in March. You can imagine her surprise when she arrived at work to find JCAHO surveyors waiting inside Kingman (AZ) Regional Medical Center at 7:30 a.m. on Monday, January 23.

"They came two weeks earlier than we had anticipated," says Pressler. "We had a plan in place but didn't get to institute it."

On the day of the JCAHO's arrival, Kingman personnel were planning to affix educational storyboards in the hospital cafeteria about questions and issues that JCAHO surveyors might ask staff. "We put them up anyway," says Pressler. "This was our plan and we went ahead with it."

"I don't think you can ever feel 100% prepared for an announced survey-we would have liked a couple of more weeks," she adds.

Kingman's five-day survey included a physician surveyor, two nurse surveyors (with an additional preceptor for one of the nurse surveyors), and a life safety surveyor because Kingman has more than 200 beds. The life safety surveyor arrived on the second day and stayed one day. The other four surveyors stayed for all five days.

The 219-bed medical center includes home health and hospice facilities, outpatient clinics, an imaging center, a cancer center, and a medical education program.

The surveyors got a quick start, conducting the first tracer by 10 a.m. Monday, says Pressler.

Read JCAHO's survey prep guide

The survey approximated the process outlined in the JCAHO's survey prep guide, which is available in the hospital area of the JCAHO's Web site ( www.jcaho.org) , says Pressler.

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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