Accreditation

Daily check of extranet site buys one hospital two hours of prep time

Briefings on The Joint Commission, June 1, 2006

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After reading this article, you will be able to

1. -recite what time the JCAHO posts notification of survey to an organization's extranet site

2. -list some of the documents and information that surveyors want upon arrival for survey

3. -define what makes a clarification to a requirement for improvement (RFI) acceptable

4. -recall a method for having materi-als ready for surveyors

Anticipating their unannounced survey in March-the anniversary of their last triennial survey-but knowing that JCAHO surveyors could show up anytime during the calendar year, two managers at Southeast Alabama Medical Center split responsibility for checking their JaycoT extranet site every day beginning January 15.

In retrospect, it was a wise decision, because JCAHO surveyors arrived February 7 to begin a four-day survey of the 400-bed facility in Dothan, AL.

"They came a month early," says Teresa Kohnhorst, RN, quality coordinator/clinical analyst, who alternated site checking with the facility's JCAHO coordinator. "We usually checked from home, but we happened to be at work that morning,"

The JCAHO's central office posts survey notification to an organization's extranet site at 7 a.m. EST on the day of the survey. Along with a letter from Russell Massaro, JCAHO executive vice president of accreditation and certification operations, surveyor bios and photos and the survey agenda also are posted.

Being in the Central time zone, Southeast Alabama Medical Center knew that it would benefit from an extra hour to prepare for surveyors to arrive, so it made sure to check the extranet site at 6 a.m. every day. That decision also paid off.

"We checked it at 6 a.m., and at 6:04 everything was posted," Kohnhorst says. "[Surveyors] arrived at 7:55, so we essentially had two full hours to prepare."

Kohnhorst and her team sprung into action: They printed the materials that surveyors would want upon arrival (outlined in the JCAHO's Survey Activity Guides [SAG]), and beeped those in the organization to whom they wanted to spread the word.

"We had everything set up and were sitting there waiting for them to get off the elevator when they arrived," Kohnhorst says. "They were blown away. They couldn't believe we were as prepared as we were."

Preparation was no accident

Despite what Southeast Alabama Medical Center was able to accomplish during those two hours, it was actually the work done long before that helped it to be prepared.

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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