Accreditation

California hospital relies on training, preparedness for a successful unannounced survey

Briefings on Accreditation and Quality, September 1, 2007

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On a Monday morning in June, a staff member at Loma Linda (CA) University Medical Center (LLUMC) checked The Joint Commission's extranet as part of her daily routine and saw that surveyors were expected to arrive at LLUMC shortly. With this tiny amount of advance warning, facility staff members immediately began following the established plan for survey visits, which included notifying all managers and directors whose presence would be expected, as well as setting up a conference room that the surveyors could use for the week. Once Virginia Mullen, RHIA, director of regulatory effectiveness at LLUMC, retrieved books full of documents needed for the survey-including the Statement of Conditions, a copy of the facility's license, medical staff member rules, regulations and bylaws, and other necessary documents listed on The Joint Commission Web site-from her locked office, the full unannounced survey began.

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