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JCAHO surveyors prefer speaking to frontline staff in new survey process

Nurse Leader Weekly, June 28, 2004

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The ultimate lesson that Mary Jaco, RN, MSN, nursing director of inpatient services at Shriners Hospital for Children, learned during her February 2004 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey is that the new survey process makes more sense because it is completely focused on the patient rather than how pretty a policy and procedure manual may be.

One nurse surveyor toured Shriners over a three-day period, and rather than meet with hospital leaders, the surveyor preferred to chat with frontline works, patients, and their families, says Jaco.

Here are two changes in the survey process that Jaco found noteworthy:

1. The nurse is the spokesperson. The JCAHO now prefers to talk to frontline staff members rather than managers because these are the folks with the hands-on patient care. Jaco had heard about this prior to survey. But what she didn't realize was that the surveyor heavily relied on the nursing staff to paint the full picture of patient care.

While the surveyor was speaking to one nurse, she asked about the nutritional screening process. This was no problem, as this is a direct nursing role. However, the surveyor then asked about the dietician's role, which a nurse may not necessarily know.

"The nurse is now seen as the center point person for the patient in the eyes of the JCAHO," she says. "So the nursing staff must be aware of what all the other departments are doing."

2. The JCAHO expects consistent answers among staff. The surveyor, after talking to the nurse about the dietician's role, will then talk to the dietician to find out whether he or she offers the same information. The surveyor wants to see consistency between what the nurse says and the dietary screens show, Jaco says.

Likewise, the surveyor asked one nurse about how she treated a patient's pain on a particular shift. The surveyor checked with other nurses on the same shift to see whether everyone treats pain in the same manner and can respond accordingly.

"The surveyor asked about patient-specific issues when looking for information, rather than general hospital questions," she says.

The surveyor also asked physicians about ordering medications for pain. After asking as many as eight questions about pain medications and the ordering process, the surveyor would then walk up to a nurse on the unit and query about the same process.

Double checking the same piece of information among many staff members means that surveyors will surely discover any weak areas, Jaco says.

Note: Shriners Hospital for Children in Galveston, TX, is a nonprofit burn specialty hospital with two inpatient units; a 15-bed intensive care unit and 15-bed plastic reconstruction. The daily outpatient population averages 50.

-Adapted from Briefings on JCAHO, published by HCPro, Inc.

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