Unannounced Surveys for Hospitals Teleconference

From HMCwiki

On March 9, 2006, JCAHO held a free teleconference entitled Unannounced Surveys for Hospitals Teleconference regarding the new unannounced surveys. They had representatives from three recently-surveyed hospitals discuss their experiences and answer a few questions. The complete transcript from this discussion can be read on JCAHO's website.

The three hospitals involved in the discussion were Select Specialty Hospital of Western Michigan, Merrimack Valley Hospital, and Aurora Sinai Medical Center representing small, medium, and large hospitals, respectively.

Q&A

Here are a few selected questions from the Q&A session at the end of the call. These are summaries only; please see the transcript for full responses. For Pharmacy-related answers to topics such as Medication Reconciliation, please see Pharmacy experiences with JCAHO.

QUESTION: What the process was for selecting staff members for personnel file and transcript review
GLORIA SWANBON: reported that they selected files based on staff members that they spoke with during the tracers and felt that the physician credentialing files were similar to the traditional surveys. They asked for the Chief of Staff, the Chairman of the departments, the most recent credentialed person, someone who had requested a leave of absence, someone that was low competence. In the Human Resources file they looked for job descriptions, three month and annual evals, the competencies, etc.

QUESTION: At a recent conference we were told that Joint Commission is going to do postpatient discharge calls. Did they do that at your facilities?
ANSWER: None of the respondents believed that they did.

QUESTION: When the surveyors came did they ask you for a list of incomplete records or a list of delinquent records?
GLORIA SWANBON: reported that they asked only for numbers of incomplete and delinquent records.

QUESTION: How did you comply with the public notice requirement that we used to be able to do before when we knew the surveyor was coming. How are you doing that continuously?
ANN STAROSZCZYK: I can speak for Aurora Sinai and what we did was include the statement in our patients rights brochure and we also had that on our Internet site for the hospital. It’s listed under Patient Rights and how to contact Joint Commission.

QUESTION: My question is basically related to offsite or outpatient type centers. Can anyone shed some light on any experiences that you had?
DR. JEFF SMITH: "We do have a large number of outpatient sites off campus, and they visited a whole smattering of them up to 15 miles away so it was pretty extensive. When they went there they were asking many of the typical questions that you would expect about reviewing medical records, even giving staff files for review as well. So pretty typical of what we’ve experienced at outpatient health centers in the past."
ANN STAROSZCZYK: said the surveyor would be going to 50 percent of their off sites.

QUESTION: My question is related to the Life Safety Engineer and your experiences with this new process versus prior surveys when you didn’t have this engineer.
ANN STAROSZCZYK: Definitely it was much more challenging than it was in the past. We don’t have our Plant Operations Manager here to answer your question but definitely much more involved than it has been. The engineer definitely, you know, is able to look at different aspects which probably have not been looked at in the past.

QUESTION: We just recently heard from another facility that surveyors are not looking into the unapproved abbreviations.
JOE CAPPIELLO: I would say that that’s absolutely incorrect. That is one of our National Patient Safety Goals. We have talked about this extensively on the side of patient safety and quality and I would expect that that would be looked at any time our Joint Commission staff is at your facility.

QUESTION: Yes, I was just curious to know when the surveyors were conducting the tracers, how much focus was on the actual systems and the hand-offs and identifying gaps and processes.
GLORIA SWANBON: Hand-offs are a very important piece of the tracer. It is a question that they ask all the disciplines. They want to know how they know about their patients and all of the relevant information. They want to know how they share information with the different disciplines. We have patients that go from the med surg unit to the Psych unit. The transfer of information on the assessment and care plans was looked at very carefully to make sure that on the med surg unit, the psych needs of the patient were addressed and on the psych unit the medical needs were addressed. So, I would say that hand-off of information is very important in this process.

QUESTION: What kinds of questions were medical staff members asked during tracers?
DR. JEFF SMITH: I think there were very similar questions that would be asked of almost any staff member. There were questions about patient identification. There are questions about communication of information and hand-off. Our interventional radiologist they were asking about site marking. They were asking about communication of result for the Interventional Radiologist. How he communicated that information back to the patient’s primary care physician. One of the questions that came out was actually of the staff – how they would know what our residents are capable of doing and the competency of our learners. So that’s something that’s unique to educational facilities. But really they were asking the doctors what they do as part of their work and how the address the National Patient Safety Goal, similar to the questions and standards that they asked everybody else about.
TORREY HUSSMAN: The other things that they asked two of my leaders on the Med Exec Team were issues about credentialing. In fact our surveyor was a physician so there were a lot of questions about that. Looking at the process, looking at the individual, looking at peer reviews, there was a lot of digging into exactly how we go through the credentialing process and to see if that person – physician who is applying for privileges onto our unit – is competent enough to be able to service the patients we have and to be competent enough to be on our floor. And there was a lot of discussion around that as well as the other direct patient care stuff but it was primarily focused on those two physicians because they’re on the Med Exec as well.

Related links

A small hospital's experiences with JCAHO
A medium hospital's experiences with JCAHO
A large hospital's experiences with JCAHO
Coping with JCAHO changes
JCAHO (definition)
JCAHO surveys by department
Pharmacy experiences with JCAHO
Preparing for an unannounced JCAHO survey
Preparing your staff for JCAHO
Unannounced Surveys for Hospitals Teleconference
Rehabilitation Services experiences with JCAHO
The morning of the survey

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