Readers assess performance of JCAHO surveyors
November 1, 1999 6 minutes read
Readers assess performance of JCAHO surveyors
Quality managers give agency qualified approval
Results from a small response to Hospital Peer Review’s most recent fax-back survey reveal that while readers rank staff at the Oakbrook Terrace, IL-based Joint Commission on Accredita tion of Healthcare Organizations (JCAHO) high in terms of helpfulness, some experienced significant problems with Joint Commission surveyors during the survey process itself.
Nearly all of the 28 respondents rated Joint Commission staff as always or sometimes helpful when contacted for information or clarification, but barely half said JCAHO was sometimes or always responsive to the needs of health care facilities. Eight of the 28 respondents reported difficulties in accommodating Joint Commission surveyors. Generally, the respondents rated surveys conducted by the Health Care Financing Administration (HCFA) and state surveyors as being more difficult but less inclusive than their most recent Joint Commission survey. Only one of the respondents is currently considering dropping the Joint Commission in favor of being audited exclusively by HCFA or the state.
In terms of how staff were prepared for the most recent Joint Commission survey, 25 of the 28 respondents conducted practice surveys, 18 cleaned up record keeping in advance of the survey, and 14 hired an outside consultant. Not surprisingly, the most common emphasis of the Joint Commission surveyors was restraints (21), followed by JCAHO standards/record keeping (13), sentinel events/root-cause analysis (9), and eth ics/compliance (8). Other areas of emphasis reported were performance improvement projects, credentialing, legibility of charting, confidentiality, environment of care, infant security, conscious sedation policies, and clinical pathways. The respondents’ average score was 93.7, with 87 as the lowest reported score and 100 the highest.
HPR followed up with three of the survey respondents for a more in-depth look at how they prepared for their most recent Joint Commission survey and how that survey went.
• New Mexico VA Health System, Albuquerque.
Renee B. Lameka, RN, MPA, chief of performance improvement at New Mexico VA Health System, began preparing hospital staff a full year in advance of the facility’s Joint Commission survey, using a unique, multifaceted approach to staff education.
"My idea was to have contests, puzzles, whatever our group could come up with to stimulate learning and make it fun," she says. As an added incentive to encourage participation in the educational effort, Lameka and her team developed a list of prizes to give out to staff members who scored 100% on any of the various learning activities (usually involving answering 10 JCAHO-related questions).
To start with, they gave away 500 turquoise T-shirts embroidered with "JCAHO" and a star symbol to activity winners. Mugs with the same logo were also given out as prizes, and staff were allowed to wear their prize T-shirts on "Joint Commission Fridays," during which a prize patrol would circulate through the hospital asking Joint Commission-related questions. Those who answered questions correctly were given small prizes, such as candy bars, packages of popcorn and cappuccino packets — all stamped with same JCAHO Star logo as well as the VA logo.
Start about nine months out
In addition, a drawing was held every month using the names of everyone who had scored 100%. The grand prize was a parking space of the person’s choosing for one month. "And on a 100-acre campus, believe me, that was very popular," Lameka says.
She initiated the educational effort in June 1998 in anticipation of a February 1999 survey. Ultimately, the survey was pushed back to June 1999, "so we sort of backed off for the holidays and started again in mid-January," she says. "My recommendation is that starting about nine months out or a little bit more is about right for these intense activities. But you’ve got to prepare for them ahead of time."
Even with months of preparation, however, the survey process at New Mexico hit a few unexpected snags. The problems began with the draft survey schedule, which JCAHO sent to Lameka around the first week of May — only about a month before the survey was to take place. "I can’t even begin to tell you how screwed up that survey schedule was," Lameka says. The most significant problem was the omission of a visit to the pharmacy. "Because of their errors, it took me four times to get the schedule straight," she says. "Then I [didn’t get] the specialty schedules. I had to beg for those. And, by the time the surveyors decided to call me, we were getting down to the wire."
When the survey began, problems continued, owing in part to the surveyors arriving late. At the end of the day, the surveyors stayed at the hospital until 6 p.m. talking among themselves, a fact that didn’t sit well with Lameka. "I had been here since 6 a.m. My attitude was, if they wanted to discuss what they had seen among themselves, they should go back to their hotel. Not that there’s anything to hide, but I still didn’t want them wandering around," she says.
New Mexico scored very well on its survey, but in some ways, the experience left a bad taste in Lameka’s mouth. "[The surveyors] were very professional and accommodating," she says. "But I lost control on the first day, and I should never have let it happen."
• Adams County Memorial Hospital, Decatur, IN.
Difficult issues also arose in Adams County Memorial’s survey — the hospital’s first-ever Joint Commission survey. Problems first became apparent during the initial interview with administration, when it became clear that the surveyors were not aware that this was Adams County Memorial’s first survey. When administrators informed them that it was, "all three of them just kind of sat there and looked at each other. Then they had to adjourn and regroup," says Peggy A. LaFontaine, RN, infection control practitioner, who at the time of the survey was also in charge of performance improvement. "It took them all of one morning to regroup, which threw off our agenda a whole half of a day."
Then the surveyors decided they wanted to juggle the schedule, moving the performance improvement presentation from the very beginning of the survey to the end. "Well, we had everyone, including the physicians, whose time is valuable, set up to be there [for the presentation] at the beginning," LaFontaine says. The surveyors ultimately relented. "However, when they surveyed our nursing home, they put the performance improvement presentation at the very end of the survey. That was bad, because until I gave that presentation, they did not know the connection between our nursing home and the hospital, and why our people here in administration spend so much time at the nursing home. They did not see how [the nursing home’s] performance improvement measures fed into our organization’s whole quality council."
Without that information, misunderstandings arose among the surveyors. The nursing home staff even began to fear the facility wouldn’t be accredited. When LaFontaine was finally allowed the opportunity to explain how the entire organization fit together in terms of performance improvement, the situation was quickly resolved. "All of a sudden, it must have dawned on [the nursing home surveyor] how all this fit together and she quit writing questions and told me I ought to publish what I had done. I was totally amazed that she had been so hard to convince."
Like New Mexico, Adams County Memorial ended up getting high marks from the Joint Commission. Even so, LaFontaine and her colleagues gave serious consideration to the possibility of not using the Joint Commission again. "We seriously do not understand why there was that much difference between what the state surveyors do when they come here and what the Joint Commission surveyors do," she says. "I think they just need to get together."
Ultimately, the decision of whether to continue with the Joint Commission was largely taken out of the hospital’s hands, however. That’s because "the Joint Commission got on the boards of the insurance companies and convinced them that if [a hospital] isn’t Joint Commission-accredited, then people shouldn’t go there," LaFontaine says. "So, in order for us to compete for contracts and stay alive, we have to stay with the Joint Commission."
• Contrastate Healthcare System, Freehold, NJ.
Some surveys, of course, go quite smoothly, as was the case at Contrastate. Mary Marinaro, RN, MPA, assistant vice president and corporate compliance officer, reports that the Joint Commission was "very cooperative" in working out the survey schedule. "On a couple of occasions, I called the standards department to get clarification on some standards, and basically didn’t get anywhere until I went all the way to the top myself," she says. "That was kind of the bad side. But [the surveyors] were very cooperative when they were here. It was a collaborative effort. If we needed to change something while they were here, or they needed to change something, it was no big deal. I haven’t really had any major problems with them. I think if you really prepare for it and you’re organized, it goes rather smoothly. That’s not to say [a survey] isn’t hectic, but there were no major bumps in the road at all."
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