A large hospital's experiences with JCAHO

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On March 9, 2006, JCAHO had a conference call regarding unannounced surveys and here are some highlights from a large hospital's experiences with JCAHO. The complete transcript from this discussion can be read on JCAHO's website. JCAHO asked representatives from Aurora Sinai Medical Center, a teaching hospital in downtown Milwaukee, Wisconsin with 386 acute-care beds. Speakers were Ann Staroszczyk, Director of Quality Management and Dr. Jeffrey Smith, Regional Director of Medical Operations.

1 How they prepared
2 Experiences with survey
3 Advice
4 Related links

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How they prepared

Using the philosophy that if it's fun, it will help the learning process, they had the following learning tools:

The JCAHO Jingle (a video set to music showing various standards in practice.) Staroszczyk said "People seemed to enjoy that. They got to see people within their department and very often we heard people humming the tune as they were going down the hallways."
JCAHO Bingo that the staff can complete with rewards of gift certificates.
JCAHO Jam, their online JCAHO education tool.
JCAHO question of the week - managers discuss and post in their own department, and since it’s just one question it’s easy enough to quickly review.

Quality Management maintained the JCAHO Binder, with all the important documents surveyors want when they arrive

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Experiences with survey

The surveyors immediately asked for a list of patients, diagnoses on each unit, contact people for individual departments
They had a five-day survey with a physician, nurse, ambulatory surveyor and then also had a one=day life safety survey.
The physicians had the most formal interaction with the surveyors, but the surveyors did speak to physicians as part of the tracer rounds. They spoke to cardiology fellows, the interventions radiologist.

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