Credentialing & Privileging

Impact of unannounced JCAHO surveys on credentialing

Credentialing Resource Center Connection , April 18, 2003

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Dear Credentialing Colleague:

As most of you now know, the Joint Commission on Accreditation of Healthcare Organizations recently announced that it will survey hospitals on a completely unannounced basis starting in January 2006. However, any hospital may request a "totally unannounced" survey prior to that date.

Just what does this change mean for the credentialing process? To answer this question, we must review the steps many hospitals take as they prepare for a traditional announced survey. They dust off the credentials files and try to second-guess which ones the surveyor will select for review. These files are carefully screened to ensure validity of current license, education, training, and experience, and to make certain the appropriate department chair appropriately documented its biannual re-evaluation. Any reappointments that were not processed within the JCAHO-required 24-month time period are hurried through the system, and documents of temporary privileges are conveniently segregated.

Under a completely unannounced survey system, the above-described preparation time is eliminated. Picture the medical staff services professional getting the following phone call from a hospital administrator:

"The surveyors are here! The surveyors are here! To arms! To arms!"

It's true. There still may be some time for playing old games. But more likely, surveyors under the new system will be different from those of the present system. I am willing to bet that "unannounced" surveyors will say, "Show me the credentials files." They will then select the files they wish to review and ask for any file documenting the use of temporary privileges. They will seek out files that document the granting of complex privileges and will pay particular attention to the reappraisals of physicians nearing or passing retirement age.

While unannounced surveys probably won't really change the way credentialing professionals do their job, but the element of surprise could make a great difference in credentialers' day-to-day adherence to JCAHO standards. After all, the patient comes first and an excellent credentials file should be able to withstand surveyor scrutiny at any time.

That's all for this week.

All the best,

Hugh Greeley



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