Nursing

Prepare your unit for a random unannounced survey

Nurse Leader Weekly, March 7, 2003

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Hospitals must ready themselves for the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) random unannounced survey (RUS) topics for 2003. Infection control (IC), performance improvement (PI), and human resources (HR) planning are some high-risk focus areas that you and your facility must take a close look at.

Consider the following tips from industry experts in the three new subject areas. These recommendations will ensure that you are on track and ready for a surprise knock at your hospital door:

Implement ongoing training: The training sessions can include mock random unannounced drills, quizzes, and games. Involve all levels of staff on its JCAHO teams. Over time, this has proven very beneficial to expanding all employees' knowledge.

Start a "JCAHO Alert": Some facilities have a system that entails alerting hospital staff through the overhead pager system that an unannounced surveyor is onsite.

Form a telephone tree: Once administrators know that a JCAHO surveyor has entered the facility, they contact all secretaries, who in turn call department heads. Within five minutes, everyone in the building should know that the surveyor is there.

Perform a quick facilities check: Immediately check to ensure that hallways aren't blocked by gurneys or wheelchairs (although you should never let this happen in the first place). Create an environmental checklist to ensure that you perform regular spot checks.

Be flexible: Although you will face an initial interruption in your work day to accommodate the surveyor's inspection, you'll have to be able to quickly change gears, and with a smile. Let the surveyor do his or her thing, and don't look annoyed.

Have a manual ready: Work with your colleagues to develop a manual with detailed instructions on how to react to a random unannounced survey. Keep this information readily obtainable in the administration office. This tactic may make the most sense for a larger organization with numerous records that are difficult to pull within minutes. The manual should contain all the documentation you might need-such as copies of the most recent credentialing files, newer employee files, and a building's Statement of Conditions-so you don't have to run around and pull files at the last minute.

Adapted from: Briefings on JCAHO, www.hcmarketplace.com/Prod.cfm?id=16&=ENMW.



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