Help your facility prepare for unannounced JCAHO surveys

Nurse Leader Insider, January 8, 2007

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It sneaks up. It creeps up. Quietly, before you are completely ready, it's there.

But unannounced JCAHO surveys, which began in January 2006, don't have to resemble horror movies or even seat-gripping dramas. With some help from hospitals that have already been there, the surveys can have happy endings every time.

During "Are You Ready for JCAHO Unannounced Surveys? Tips from the Field," a recent HCPro audioconference, Hector Hernandez, MBA, CPHQ, ACHE, the chief operating officer at East Los Angeles Doctors Hospital and Eileen Pressler, RN, BA, CPHQ, CCM, the performance improvement and accreditation coordinator at Kingman (AZ) Regional Medical Center, laid out a number of different tactics to help your hospital succeed. From storyboards to mock tracers, they offered tips to prepare for that fateful day.

Making sure you are ready

Pressler and Kingman Regional strived to be on the ball. They studied the Survey Activity Guides (mini survey instruction manuals issued to all JCAHO-accredited organizations), formed a JCAHO steering committee, and conducted two mock surveys.

They also used a storyboard education plan, decorating the hospital cafeteria with major topics for which staff would be responsible. They made sure to make them simple and geared to all members of the staff.

On January 23, 2006, the surveyors arrived earlier than expected. The first day, Pressler says, was the worst. After only three hours, the surveyors-a physician, a nurse, a home health/hospice nurse surveyor and her preceptor, and a life survey surveyor-began doing tracers that focused heavily on National Patient Safety Goals. The two following helpful hints, Pressler says, helped the facility get through the day:

  1. Use one main contact person to do the coordinating. "I recommend using one person to get the policies and procedures, and notify people where they need to be," says Pressler.
  2. Have a staff member with each tracer. "If you decide to do that, have your staff listen closely to what the survey team member is talking about. We felt that often gave us a clue as to what employee folders might be pulled later or where the next tracer might lead them," she says.

Days two through five went much smoother, Pressler says, thanks to daily schedules-based on the Survey Activity Guides-compiled by the main contact person.

Editor's note: For a copy of the 90-minute audioconference, visit or call our Customer Service Department at 877/727-1728.

Source: The Staff Educator, January, 2007, HCPro, Inc.

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