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Prepare yourself for a 2006 unannounced JCAHO survey

Ambulatory Safety Monitor, June 2, 2005

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Come January 1, 2006, the JCAHO will conduct all surveys unannounced. This means no more cramming; from now on, continual compliance is expected. Starting next year, a JCAHO surveyor will arrive at your facility without notification any time two to four years after your last survey.

You can no longer rely on last-minute planning and staffing. Maintaining staff education, identifying and improving weak processes, and staying on top of JCAHO standards will be the key to your success.

Educate all staff on NPSGs related to their job

Surveyors are spending less time talking to leadership and more time talking to staff, so it's more important than ever to educate all staff in your facility-from housekeepers to anesthetists.

"All staff must be able to verbalize their understanding of how the [National Patient Safety Goals] relate to their job under the new survey system," says Dee Williams, RN, CASC, administrator of Surgi+ Care in Maumee, OH, whose facility was surveyed under the new system at the end of February. "Our surveyor didn't even ask for our policy and procedure book; his focus was on our staff," Williams says.

To help prepare her staff for survey, Williams created a core JCAHO prep team for each department at Surgi+Care. Each prep team had a team leader, and regular staff meetings were held to educate staff about compliance issues.

Williams also used custom videos of mock tracers to help train staff. "Providing staff with a visual of how they're expected to respond to a surveyor helped them feel more familiar and less intimidated with the new survey process," she says. The videos drove home the fact that surveyors didn't want staff to memorize standards; they wanted staff to verbalize their responsibilities and to know that they increase patient safety, says Williams.

Conduct mock tracers to identify weaknesses

The unannounced survey system centers on patient tracers, so conduct regular mock patient tracers, suggests Philip Landry, MD, former ambulatory surveyor for JCAHO and current consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, which publishes this ezine.

"Trace a patient from admitting to discharge and document any weaknesses you find along the way," Landry says. "Then, when you conduct future tracers, give special attention to the weaknesses you've previously identified."

When conducting mock tracers, Landry suggests you keep an eye on the following:

• Updated medical chart handoffs between nursing, the operating room, and recovery

• Patient privacy

• Site marking

• Patient consents

• Updated history and physical charts

• Time outs

• Complete evaluation of airways

The JCAHO will focus on these three ASC areas

Your facility should strive for compliance with all JCAHO-related standards, but there are specific areas to which ambulatory surgery centers (ASC) should pay attention, including the following:

• Medication management. "Surveyors are finding a lot of deficiencies with how ASCs are storing and handling medications," says Landry. "All medications must be labeled and either locked or under constant supervision." The JCAHO expects you to handle sample medications like any other drug in your facility.

• Credentialing. "One of the reasons our surveyor spent so much time with staff was to verify competence," says Williams. The surveyor who visited Surgi+Care also spent time checking competency tests and credentials to make sure they were valid and up to date. The JCAHO will check for age-related competencies, especially for nursing staff.

• Performance improvement. "Simply gathering performance improvement data is not enough," reminds Landry. "JCAHO wants to know how you're improving patient safety with the data." The JCAHO expects you to review your performance improvement goals at least annually or when your services or patient population changes.

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