Preparation is key to JCAHO survey
Your agency can’t get ready at the last minute
Martha George, owner of Spring Hill, TN-based consulting firm Healthcare Accreditation Consultants, remembers innumerable times she has received calls from home health agencies saying, "The surveyor is coming next week. Can you help us get ready?"
It is in some ways exasperating, says George, and in some ways indicative of how busy agencies are just trying to survive. "They just don’t spend the time getting ready for a survey that they ought to," she says.
There are major drawbacks to not preparing for a survey by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) in Oakbrook Terrace, IL, says George.
Those range from Type 1 recommendations and focus surveys that eat up time and energy to conditional accreditation or even losing it altogether.
Going above and beyond
"Not preparing for a survey simply means you won’t do well," says George. "There are people out there who say they obey the law, do well on their state surveys, and then assume that means they’ll do fine on a Joint Commission survey. But the commission goes above and beyond."
She recalls one home health agency that purchased a manual to prepare for its first survey. "But the manual was based on 1993/1994 standards, and this was 1996. They put it on the shelf, figured they were doing a good job, trying hard, and the commission would understand. Instead, they got nailed on infection control, care planning, safety, equipment management, and performance improvement."
The agency was given a focus survey date six months down the road, but didn’t call George until the day before JCAHO was scheduled to arrive. "I couldn’t do anything for them," she recalls. "The only thing I could do was get them ready for the second focus survey, four months later."
The preparation worked, and the Type 1s were removed.
George likes nine to 12 months to prepare an agency for a first accreditation survey, and 18 months for triennials. The length of time often seems daunting to agencies, she admits. "It can be accomplished quicker, but that requires more intensity." In addition, if you have to show 12 months’ process for your triennial, you really need more than a year to implement and evaluate programs. "The ideal would be to maintain readiness to avoid hectic preparation. However, I have never seen this."
The rationale for continuous preparation is sound, notes George. "We see people coming to their next survey, and we are doing the same things time and time again, making the same recommendations," she notes. "It’s just a waste of time and money. But people lose their focus. When the commission comes, all their efforts are there. Then when the survey is done, the focus is on building revenue and business, and just keeping the agency open. Especially now."
George’s firm has started a maintenance program for agencies. She and her staff go into agencies quarterly to evaluate policies, procedures, and programs. But she says an agency can have their own continuous preparation strategy simply by forming a master committee to oversee survey preparation.
Sometimes, an agency’s management committee takes on this role. Other committees, such as safety, performance improvement, and infection control should meet monthly to go over the areas of the JCAHO standards manual that apply to each. Some areas, such as ethics, need only be evaluated once a year. If you have a small agency, George says you can bundle these committees into one committee.
George believes strongly in creating checklists of tasks that need to be accomplished, as well as accompanying time lines and deadlines that someone at the agency is responsible for meeting. Those deadlines should be realistic and have some "grace time" built in.
Committees can develop lists of questions to ask themselves in advance of a survey that will help them to determine whether they are ready. (For a sample list of questions, see box, p. 170.)
Regular check-ups of each section of the manual are a must for preparation, she says, advising that agencies pick one section per month to go over. Don’t skip anything, George adds. Agencies that have survey problems can make mistakes in any area, she notes. (For a list of commonly overlooked areas, see related story, p. 171.)
The bottom line is that failing to prepare for a survey means running the risk of dragging out the accreditation process. "That increases frustration among staff, makes it hard to focus on other projects, and you can even lose accreditation."
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