AUG./SEPT 2006 Volume 30 No. 8

The five-day visit conducted July 24 by four surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) was unlike any site survey we have experienced before.

To begin with, we had invited the reviewers to come look at our practice, staff, policies and facilities and then tell us how well we were complying with JCAHO standards. Such a move would have been laughable a decade ago, akin to inviting the fox into the henhouse. After all, most hospitals prepared for site visits by scrubbing down the place, passing out crib sheets of prepackaged “right answers,” and then trying to put on a face perceived to be expected during such an event.

But our last official visit from JCAHO in April 2004 was the final scheduled “announced” survey, and hence, the driver of our precedent-setting invitation. You see, sometime in the next year we will be visited again by JCAHO, but this time the arrival will be unannounced and could occur at any time. This change is central to JCAHO’s strategy to guide SHC and all institutions into a state of “continual readiness.” The commission wants us to show the surveyors our ongoing quality, not how well we can “cram for the exam.”

So how do the changes make our July invitation to JCAHO seem less odd?

The answer lies primarily in the new philosophies and approaches to accreditation. As a condition of accreditation, the JCAHO now requires us to submit a PPR (periodic performance review) to assess how well we adhere to accreditation standards in the months and years between surveys. Institutions can either do a self-assessment, as we have done in the past, or they can bring in consultants, including members of JCAHO survey teams, to perform the task. We felt that we would get the most accurate feedback and also become more familiar with the tracer format (following individual patients through the healthcare process) of surveys by making the assessment as realistic as possible. And who could do that better than the JCAHO itself?

To understand why these surveys and resulting accreditation are so important, let’s look at a little history. In 1951, the American College of Physicians, the American Hospital Association, the American Medical Association and the Canadian Medical Association all joined with the American College of Surgeons to create the Joint Commission on Accreditation of Hospitals (JCAH) as an independent, not-for-profit organization. The mandate was to offer voluntary accreditation for hospitals to ensure they were maintaining certain standards and to help improve the care and treatment of patients. Recognizing changes in healthcare, the name was changed to JCAHO in 1987, as the organization expanded its activities to accredit many types of healthcare entities, including homecare agencies, hospices, nursing homes, etc.

More recently JCAHO has grown a consumer face. Members of the public increasingly look to JCAHO through published surveys, the web and the news media as a resource to learn about the quality and safety of the places where they might seek health care. So not only does the survey process help us to organize and strengthen our patient safety efforts, but accreditation also ensures that we maintain credibility in the marketplace. The bottom line is that accreditation is the right thing to do.

I found the most recent voluntary visit to be extremely helpful and educational. The surveyors pointed out some weaknesses, but they also gave us kudos for several areas where we demonstrated “best practices and exceptional care of our patients”:

Several of our staff members received compliments for the excellent manner they answered questions about their patients and about hypothetical scenarios.

Perhaps the most positive and telling comment came from a surveyor who said the residency teaching he witnessed prompts him to recommend to his own child one of our training programs ahead of his own.

Some of our staff members were praised not only for calling the required “time out” at the beginning of a procedure, but for also explaining to residents and students in the operating room the rationale and importance of this safety step.

Respective of the kudos, we clearly need work in certain areas. We did have some physicians who did not participate in the “time out” process. Some other physicians, sadly, didn’t seem to know what a “time out” was.

The surveyors found some unapproved abbreviations in a few charts they inspected, but they did say the incidence of such abbreviations was well below the level of other academic medical centers they have visited. Our P.O.E. (physician order entry) is clearly helping us communicate clearly, and certainly EPIC, our unfolding comprehensive paperless record system, will help our institution make the next great leap to eliminate use of unapproved abbreviations, while enabling many other positive changes as well.

Some other areas also require attention:

We must continue to focus on proper hand hygiene, remembering to wash or gel before and after each patient contact. Similarly, we must wash or apply gel before and after putting on latex gloves, before handling specimens, or before performing patient exams.

Some of our physical exams were deemed a bit cursory or not complete for some patient diagnoses.

We need to improve some of our forms so that we are reminded to assess pain and potential abuse (domestic, elder, child, etc.) in all situations. We have already changed some forms so that we are documenting pain assessments on intubated or sedated trauma patients.

We must ensure that we are delivering parallel care to similar patients in all venues. For example, anesthesiologists may need to be present in cath labs if their presence is already required for similar procedures in the operating rooms.

Overall, I am told 17 findings by the surveyors require some written plan of corrective action. Be assured that these issues will be checked again during the “real” survey. That being said, we should embrace survey readiness not as a necessary evil, but because for the first time in my memory, JCAHO preparation has been synchronized with best practice.

“Continual readiness” may involve effort, but it should not be seen as a counterproductive burden: virtually everything required to be “ready” makes our hospital and our practices better for our patients and more effective for ourselves. And, yes, at the same time, we will assure ourselves the accreditation that shows the public, our colleagues and ourselves just how good we are.