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Nurses who volunteer for JCAHO educational activities also receive bonus points on their performance appraisals as part of a new clinical ladder system, said Uttley, who chairs the hospital's Nursing Assembly, a decision-making body for nursing that has 19 committees and councils and covers all procedures and protocols. The groups are being brought up to speed on changes in JCAHO's assessments and standards. The products committee, for example, might focus on safety standards related to free-flow pumps or the dispensing of medications.

"We're also focusing on the environment of care and are starting to see some positive results in a short period of time," Uttley said. "We expect people to do environmental care rounds twice a month-tracking and trending-to make sure any issues are dealt with. For example, if there's a biomed or engineering issue that nurses repeatedly are asking to be taken care of, we have a system to follow through and resolve the issue."

A key reason for the VA hospital in Los Angeles to volunteer for unannounced surveys was to get a jump on integrating JCAHO's new policies and procedures into the accreditation process, said Theresa Osborn, MSN, RN, quality management officer for the VA Desert Pacific Healthcare Network.

"It forces us to truly do a deep assessment, because if we're not in total compliance, we must come up with a plan with timelines and a real course of action," Osborn said. "This can be very beneficial to us."

Quality standards

Donna Beiter, MSN, RN, nurse executive of the VA Greater Los Angeles Healthcare System, said the VA Healthcare System has established a number of quality benchmarks in the areas of patient safety, computerized patient records and barcoding.

"This pilot is the next step for us. It's not about JCAHO as much as it is about continuous readiness and quality patient care, and that's why we're very committed to it."

However, Ann Kobs, MS, RN, a former surveyor who helped develop standards and trained survey teams, remains skeptical as to whether unannounced surveys will ever become a permanent JCAHO policy. "I support unannounced surveys 100 percent, but 2006 is a long way off, and the political forces against the policy change are strong."

Kobs, who spent 10 years with JCAHO and now runs her own health care consulting business, said the JCAHO board is composed of members of major hospital and physician organizations that don't want to be caught by surprise inspections that may find areas that need improvement. "These are organizations that have fought against unannounced surveys for years," she said.

Other surveyors who have left JCAHO share Kobs' skepticism, she said. "There are a lot of us who believe the unannounced surveys are a great idea, but will be a tough nut to crack."

JCAHO's Murphy-Knoll said hospitals no longer will receive an advance agenda from the survey team. Instead, surveyors will rely on what is termed a priority focus process (PFP) that is directed to organization-specific, critical patient care processes and systems, instead of rote assessment of standards compliance.

Much of the PFP information will be gathered before the on-site survey and will be evaluated for compliance to selected standards during the analysis of a particular patient's care-a process known as tracer methodology.

For example, if PFP data identified a health care organization as having a large number of geriatric patients, a critical focus would be on medication use. The surveyor would ask for active patient files that involve multiple medications and use tracer methodology to examine prescribing, dispensing and monitoring procedures.

If problems are identified during a survey, the organization will have 30 days to devise a remedial plan of action and receive an "accredited" status at that time. JCAHO also has made other changes to streamline the accreditation process for about 17,000 health care organizations, and it will take some time to get the kinks out.

"All these steps are being tied together and will make it possible to go to unannounced surveys," Murphy-Knoll said. "They [unannounced surveys] make sense. There's no need to ramp up, and they promote continuous standards compliance, which is what we all want. It makes the accreditation process much more credible to the public and patients."

The VA's Slaughter said the tracing methodology will give surveyors a much more thorough picture of how a patient is treated than they would have received in the past by questioning the nurses and staff. "The only anxiety nurses will have now is from having someone they don't know observing their practice."

Contact John Leighty at johnsan@aol.com