Medical Staff

Unannounced surveys and survey preparation

Medical Staff Leader Connection, April 22, 2003

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Dear Medical Staff Leader,

If the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently surveyed your hospital, it is likely your next survey will come without warning. The JCAHO announced this week that it will shift to a strictly unannounced survey schedule starting in January 2006. Although you may receive slight advanced notice from the hospital across town, your survey will not be scheduled weeks in advance to allow you ample time to review the medical executive committee, performance improvement, credentialing, and other critical medical staff activities.

If you haven't been conducting ongoing drug usage review, there will be nothing you can do to mitigate the likelihood that a surveyor will find out. If your department chairs, medical staff officers, and other key physicians do not know how your performance improvement program works, it is unlikely you will be able to provide a "just in time" inservice to bring them up to speed.

If the medical staff and hospital are in the midst of a crisis such as a fair hearing, medical staff management dispute, or an investigation of last night's sentinel event, the surveyors will most likely push on with the survey and your administrative and medical staff leaders will need to "work around it."

I can picture the chief of staff, surgical department chair, credentials committee chair, and other key leaders (along with some board members) receiving a frantic early morning call from the administration asking them if they can cancel their entire day to participate in a JCAHO unannounced survey.

It's increasingly important for all institutions to be continuously prepared to demonstrate that they meet or surpass JCAHO standards--a practice that is better for hospitals, the JCAHO, and patients.

That's all for this week.

All the best,

Hugh Greeley



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