Accreditation

Culture of survey readiness important to preparing for unannounced process in any size hospital

Briefings on The Joint Commission, May 1, 2006

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by Brion McAlarney

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

1. describe how to prepare for an unannounced JCAHO survey

2. list ways to facilitate compliance with standards and best practices

Year-round preparation culminating in a culture of survey readiness appears to be a key ingredient to success in the new era of unannounced JCAHO surveys, according to several hospital officials during the recent JCAHO teleconference "Unannounced Surveys for Hospitals" held on March 9.

The teleconference included representatives from small, medium-sized, and large hospitals.

The small hospital experience

Representing small hospitals, Torey Hussman, CEO of Select Specialty Hospital of Western Michigan in Muskegan, told conference listeners that his facility started preparing for its unannounced survey six months prior to its possible survey time frame.

"We wanted to step away from the process of actually gearing up for a survey and then winding down," he said.

Officials at Select Specialty, an acute long-term care facility with 31 beds, established the concept of being ready for their next patient rather than the next survey. They learned about tracer methodology from the JCAHO and started performing a tracer first every other week, then weekly as they drew nearer to the expected survey time, said Hussman.

The tracer teams were directed by Hussman, Wanda Cooper, the hospital's director of quality care, and one other hospital leader, depending on the tracer and the time frame.

Tracer findings were directed back to staff with action plans to address process and system issues, said Hussman. The mock tracers allowed staff to feel em-powered to participate in the improvement process and become comfortable with the survey process, which helped them do well on the actual survey, he said.

The action plans became a regular part of bi-weekly hospital leadership meetings, he added.

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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