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Be ready for unannounced JCAHO surveys starting in 2006

Credentialing Resource Center Connection, October 8, 2003

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Dear Credentialing Colleague:

If the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently surveyed your organization, it's highly likely your next survey will come without warning. The JCAHO announced this past April that it will shift to a strictly unannounced survey schedule starting in January 2006. Although you might get a heads-up from the hospital a few towns away, your survey will not be scheduled weeks in advance to allow you ample time to review your credentialing, privileging, performance improvement, and other crucial medical staff activities.

If your organization hasn't conducted continuous drug usage review, for example, there won't be much you can do to mitigate the likelihood that your JCAHO surveyor(s) will find out during an unannounced visit. If your department chairs, medical staff officers, and other key physicians aren't familiar with how your organization's performance improvement program works, you probably won't have the necessary lead time to provide a "just in time" inservice to bring them up to speed.

Even if your organization and medical staff are in the midst of, say, a fair hearing, management dispute, or sentinel event investigation, the surveyors will most likely move forward with the survey just the same. You and your administrative and medical staff leaders will have to "work around" other events and challenges.

I can picture the medical staff coordinator, chief of staff, surgical department chair, credentials committee chair, and other key leaders receiving a frantic early morning phone call from administration asking them to clear their schedules to participate in an unannounced JCAHO survey. But ongoing preparedness efforts will go a long way toward eliminating such calls.

That's why it's increasingly important for all JCAHO-accredited institutions to continuously demonstrate that they meet or surpass JCAHO standards--an approach that is better for institutions, the JCAHO, and patients alike. Compliance shouldn't wait until the weeks preceding a survey, as many organizations have done in the past.

That's all for this week.

All the best,

Hugh Greeley

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