A small 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 small hospital's experiences with JCAHO. The complete transcript from this discussion can be read on JCAHO's website. JCAHO asked representatives from a Select Specialty Hospital - 31 bed facility to discuss their experiences. Speakers were Torrey Hussman, CEO, and Wanda Cooper, director of Quality Care.

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

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How they prepared

Researched and learned about patient tracer methodology
Conducted patient traces with a team comprised of CEO, Director of Quality and other applicable hospital leader. Started at one trace every two weeks and increased to one every week and performed patient safety rounds at least once a month
Findings were relayed to staff with action plans and goals. Staff were highly involved; familiar with methods, empowered to make suggestions for change
Assigned chapters of the PPR to leadership team for review
Hung a checklist in the break room and nursing station that explained what would happen in the first hour of an unannounced survey

How do you identify the surveyor and verify his identity?
Where do you take the surveyor for set up?

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Experiences with survey

The surveyor first handed them an agenda and while he was setting up/planning they notified the staff who would need to be present for a specific assessment (such as Life Safety in the EOC session). then met with leadership at the end of the first hour. Within 2 1/2 hours he was doing the Life Safety Code Assessment.
The surveyor asked for our patient list with diagnoses so he could choose what patients he would trace with a clinical service grouping.
Over the two-day period the surveyor completed four patient tracers and two system tracers
Surveyor quickly got a feel for how well staff knew their patients by asking them questions after a quick review of the chart, watching the med tech, and listening to the medication reconciliation and teaching on discharge.
Survey was not disruptive to hospital operation; surveyor was very flexible.

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Advice

Know who would be able to access HR records and credentialing records if some of your vital leadership is not present for the on-site survey.
Prepared compilations with essential documents such as the organizational chart, plans for provision of care, licensure, the FMEA, staffing effectiveness, governing board, updated statement of conditions, disaster drill critiques. All leadership should know where these documents are.

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