1. Adamski, Pat RN, MS, MBA

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Unannounced surveys, which began in January 2006, were the next logical step in the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) new survey process. By embedding the standards into everyday practice and using the available tools, organizations can change their culture from one of preparing for the next survey to preparing for the next patient.


Q If we don't know when our survey will take place, how will we be able to prepare for the JCAHO assessment?


A Being compliant with JCAHO standards should be a part of your everyday routine, not just something that you work on in the months before a survey. Having a solid understanding of the standards and how your organization meets the requirements is a good place to start. Most organizations identify a team that leads the way and monitors compliance on an ongoing basis, not just once every 3 years. Creating a team that's diverse in terms of experience, specialty, and role can provide a more robust look at your processes, procedures, and opportunities.


Education of the staff on the new unannounced survey process is also important. Having staff members that are comfortable explaining the care they provide and how they ensure quality outcomes for their patients helps the surveyors assess your organization's compliance with the standards. It's just as important that staff members in supporting roles understand their role in the systems of your organization, as they'll have an easier time meeting the expectations of the team.


Developing a strategy for the day the surveyors arrive will help everyone focus their efforts and minimize disruption. Having a list of key logistical and organizational information available for staff who are most likely to first encounter the survey team will start the day off in a positive way. Knowing whom to notify and where critical information is located will help everyone involved. Ensuring that those in responsible positions have at least one backup person who's knowledgeable and able to step in if needed gives the team a sense of security.


Q What tools are available to assist us in our quest for continuous compliance?


A The Periodic Performance Review (PPR) is a tool that contains all of the standards and elements of performance and is available to you on a continuous basis on your extranet site. The PPR allows you to assess your compliance with the standards and elements of performance and enter your findings. This information is submitted to JCAHO on an annual basis, but is available to you all the time so you can update your progress. Interacting with the PPR frequently can give you real-time information that will enable you to improve your systems and compliance.


Another important tool is the use of tracer methodology to assist in the assessment process and staff education. By using unannounced tracers and targeting times that may not be optimal in terms of staffing and activity, you can help uncover how your processes and procedures hold up when stressed. You can also see how staff reacts in stressful situations. Conducting tracers using leaders that staff may not know or be comfortable speaking with can also help develop more skill in explaining practices and patient care to unfamiliar faces.




The Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission's unannounced survey process, 2006. Oakbrook Terrace, Ill: Joint Commission Resources; 2005.