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Preparing staff for the JCAHO survey

Staff Development Weekly: Insight on Evidence-Based Practice in Education, March 24, 2006

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If your hospital cares for many children, your facility must be prepared for JCAHO surveyors to apply the tracer methodology to a complex pediatric patient when they arrive for survey.

How will surveyors follow up on this patient and what questions can nurses expect them to ask?

Surveyors might review the patient's medical record, speak to the patient or the patient's family, and discuss the case with nurses and doctors in the pediatric unit. Then, they may move on to the emergency department (ED) or the intensive care unit (ICU).

Surveyors would likely use the patient's chart to guide them through the organization's departments, policies, and procedures. They may even review the credentials files for the pediatrician and the ED physician involved in the case. They may ask questions such as, "How are consultations obtained?" or "What criteria trigger a consultation?"

Tip: Remember to take extra care to accurately document information in the patient's record. Surveyors will actively compare patients' charts to clinician feedback about the care they gave, and patient feedback about the care they received.

Editor's note: The above excerpt is from the online course, "Survey Series: How to Survive a JCAHO Survey for Nursing and Clinical Staff." For more information on this and other courses in our library, go to www.hcprofessor.com.

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