Prepare for surprises during your JCAHO surveys
Plan a few extra contingencies
Sandra Sessoms, RN, CPHQ, assistant vice president of nursing, quality improvement, and utilization review at Suburban General Hospital in Pittsburgh, relays some advice: "Make sure you have an extra team prepared to present to a Joint Commission survey team in case what happened to us happens to you."
The quality team at Suburban recently had an experience that Sessoms says she has not heard of happening to anyone else. The facility was surveyed by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, three years ago. On the second day, the visiting team told them they had done such a fine job in their performance improvement overview that instead of two teams presenting, they wanted to hear from a third team.
"Luckily, we had one in the wings," says Sessoms, "but of course those people were not as prepared to speak as the teams who anticipated making presentations. I knew which teams were stronger in presentation skills than others, and I chose from among those to do the third presentation. That was kind of tricky."
One of the teams that was prepared beforehand to make its presentation talked about the facility’s total hip arthroplasty program, and the other gave a speech on a preadmission program for total hip and knee replacement. "The team we had to add at the last minute made its presentation on a flash sterilization project headed by the infection control committee, where we assessed how much flashing we were doing and its appropriateness," says Sessoms.
Wilma McCullough, quality assurance manager at Monsour Medical Center in Jeannette, PA, adds an experience that her facility had recently. "It’s a bit difficult when a surveyor brings along someone in training. The problem is, we weren’t warned that there would be an extra person prior to the survey, and we weren’t prepared." The team at Monsour tries to keep two staffers with each surveyor at all times. That way, if one staffer has to leave for some reason, there’s still one left there with the surveyor.
"Being unprepared for the additional surveyor was difficult because before we knew it, they were going in different directions, unaccompanied." McCullough’s advice: Anticipate an extra surveyor showing up and have extra people on hand prepared to accompany him or her.
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