Security is JCAHO surveyors' first focus
'It has nothing to do with what's in the news'
Russell Massaro, MD, executive vice president for accreditation operations at the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, says it is untrue that the Joint Commission tells its surveyors to focus on areas related to media events.
"We have been looking carefully at the nursery and maternity suites for years, and security is our surveyors' first focus," Massaro says. "Nursery security has been in our standards and a part of our process for years. There is nothing new there. It has nothing to do with what's in the news."
Marcia Patterson, RN, director of obstetric services at Rush-Presbyterian-St. Luke's Medical Center in Chicago, agrees: "Our next survey is a couple years off, but during our last one - and that was before the switching event that's now in the papers - the surveyors were very interested in our newborn area security policies. So it's a topic covered regularly. But also it has a lot to do with the particular interests of the surveyors."
"We do double- and triple-checks on areas of the hospital that have been in the news lately," says Wilma McCullough, quality assurance manager at Monsour Medical Center in Jeannette, PA. "There was a problem in Pittsburgh a couple of years ago - a patient had received the wrong blood transfusion. The incident was well-publicized. Internally we were concerned; we looked carefully at our own checks and balances. But we also knew that blood transfusion policy could be an issue the Joint Commission could focus on during a survey. In fact, they didn't make a big issue about it."
Hospital Peer Review asked Massaro if a newsworthy situation ever correlates with the focus of a survey. "Surveyors are professional people," he replies. "The standards that relate to media events are part of their ongoing surveys no matter what." He acknowledges, however, that as individuals, what surveyors see in the morning paper over coffee may be on their minds when they ask questions in those high-profile areas. But the questions would have been asked anyway. "Through my years as a surveyor," says Massaro, "I repeatedly went through the rituals of checking on everything from tagging of the babies, visitor policies, and policies and procedures for handing the baby off for transport from the nursery to cameras, alarms, and all the rest. Those are part of the routine for our surveys, and it's always been that way."
The survey process is meant to examine all the standards, he explains. "But of course you can't survey all of them with every individual in the hospital. You have to sample people, and depending on the size of the organization, you sample units." Surveyors assess an organization and determine where more in-depth evaluation is necessary. "We built that into our survey process by asking the surveyors to brief one another - to hold daily meetings where they come together as a team and review their findings to date," says Massaro. "They inform each other of areas in the organization that may be at risk in terms of providing quality, safe care. Then they survey those areas more intensively. That's all part of being good diagnosticians."
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