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How to prepare for the JCAHO survey process

HIM Connection, August 3, 2004

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Because the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey process has changed, your organization must develop processes that ensure continuous survey readiness. Your first priority is changing the organization's culture as it relates to survey readiness and implement compliance educational programs. Everyone must embrace this approach to JCAHO accreditation in order to be successful.

The next steps will be a continuous educational program related to the standards themselves and how your organization complies, and well as a process for monitoring compliance. A survey readiness team or chapter teams can facilitate these activities. Your organization may already be doing this, but continuous readiness has never been more important and old methods may need to be revamped.

Patient tracers, interviews with staff and patients, and observations have replaced traditional methods of assessing compliance. Surveyors use these new methods to determine compliance with the IM standards. Documents will not be reviewed unless a surveyor specifically requests them, but it is still essential that they be up-to-date.

Surveyors may question your use of aggregate and comparative data, the confidentiality and security of patient records, your coding and retrieval system, etc.

To prepare for this new survey process, consider taking the following four actions:

1. Form an IM chapter team and conduct assessments
   This team should be lead by director of IM and include the director for information systems, the medical librarian, and representatives from the nursing and medical departments, other clinical staff, and a representative from the Performance Improvement department. The team should assess the organization's compliance using the periodic performance review assessment document.

   A word of caution: Don't wait until periodic performance review is due to begin your assessment of compliance.

   The team may want to consider the following questions:

   • Is IM training provided to all staff?
   • Are directors/managers able to show examples of how aggregate information is used to manage their departments' performance improvement activities?
   • Do staff know how to use and provide information?
   • Are all staff aware of their responsibilities for security and confidentiality of information?
   • Are external databases used to compare performance data?
   • Are policies and procedures established for the recovery of information in a disaster?
   • Are all staff aware of their responsibilities for security and confidentiality of information?
   • Do staff protect access to information in the medical record?
   • Is there a plan in place to conduct an ongoing open chart review?

2. Document the results of assessments
   Once you've rated your level of compliance with the standards, summarize the findings in a simple format that others will easily understand. Consider listing only the area that received low scores in your report and make a blanket statement that everything else is compliant. Although this appears negative, it will help everyone focus on the relevant areas.

3. Develop and implement actions for improvement priorities
   Once you've identified the improvement priorities, it's time to implement the changes. Action plans should include a completion timetable, a statement of objectives, and a description of intended results. Develop a tracking calendar to follow the progress of the action plans.

4. Prepare staff for questions surveyors may ask
   Because surveyors will be spending the majority of time on patient care units conducting patient tracers, staff should be familiar with the IM standards related to their department activities as well as the organization's overall IM functions.

Next week: Quiz questions your staff needs to know to prepare for the JCAHO survey

This excerpt is adapted from the book Information Management: The Compliance Guide to the JCAHO Standards.

Andrea Dickey
Editorial Assistant
adickey@hcpro.com   

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