Cold Calls
Hospitals sign up for unannounced JCAHO visits to get a jump on new accreditation procedures and to assure continuous assessment of patient care

By John M. Leighty
July 28, 2003

One hundred hospitals have volunteered to take part in the pilot testing of unannounced accreditation surveys-which many nurses dub "The Visit"-and Annya Slaughter, RN, said the surprise inspections could be a healthy change.

"I've been through accreditation at several facilities, and there was definite anxiety as the date approached-everybody wanted to take a vacation," said Slaughter, who works as a critical care nurse for the Veterans Administration Greater Los Angeles Healthcare System. "It's always been 'Let's get ready,' and now it will be 'Let's be ready, all the time.' "

That sentiment is also what prompted Children's Memorial Hospital in Chicago to be the first in the nation to volunteer for unannounced regular surveys in 2004 by the Joint Commission on Accreditation of Healthcare Organizations, which sets compliance standards for quality care and patient safety.

The pilot program is designed to smooth the way to make such unscheduled visits permanent in 2006.

"We always felt well-prepared for JCAHO visits, but I like the change to unannounced surveys," said Shelley Uttley, RN, special projects manager at Children's. "There was a tendency to go into high gear as the survey time got closer, and the approach now is that we always want to be in high gear.

"What I'm really trying to do is change people's mind-sets, so if surveyors walk through the door tomorrow, we're ready."

Linda Murphy-Knoll, vice president for accreditation service operations for the Joint Commission, said a paradigm shift will take place in survey procedures starting Jan. 1, with the transition to unannounced visits in 2006 being the final step in the process.

Patient focus

Under revised JCAHO guidelines, scoring will be eliminated, along with general departmental inspections and many formal interviews, Murphy-Knoll said. Instead, surveyors "will really look at patient care. They'll follow specific patients through the system and look at the critical issues from that point of view."

Before such performance evaluation, hospitals will prepare self-assessments-now called periodic performance reviews-related to quality care and patient safety. "We'll look at the processes and make sure they're in compliance with our standards before ever going on-site," Murphy-Knoll said.

She said she has received positive e-mails from staff nurses who like the new idea of randomly selecting patients for evaluating standards of care.

"Nurses see the process as very credible, and many have been pushing for this for years. They want us to really look at what's happening in hospitals, not at what is prepared for an accreditation visit."

Uttley said she's been "living and breathing" JCAHO awareness since being in charge of preparing Children's Memorial nurses and staff for unannounced visits and the changes in how evaluations will be done.

She said nurses were taking part in a big push to keep patient safety and staff effectiveness "in people's heads" and that a JCAHO preparedness fair was being planned. The fair would use entertaining ways to educate the staff, such as flash cards, games and interactive computer programs that focus on safety standards and optimal practices, Uttley said.

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 M. Leighty at johnsan@aol.com