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JCAHO Announces Major Revisions to Survey Process

Kate Traynor

Beginning in January 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) says its survey process will more directly assess patient care and safety than it currently does.

New components of the survey process for all accredited organizations include a self-assessment before the onsite survey and the use of so-called tracer methodology to track the progress of patients as they seek care. According to JCAHO, many standards are being consolidated and streamlined and their clarity improved.

JCAHO President Dennis S. O’Leary, during an October 3 press conference, described as "revolutionary" the collective changes taking place at the accrediting agency. JCAHO has dubbed the new accreditation process "shared visions—new pathways." The new process is described in detail in the October 2002 issue of Joint Commission Perspectives, which is available at

Having organizations self-assess. Using a secure, online module, organizations that seek accreditation or reaccreditation will complete a self-assessment survey to rate compliance with appropriate standards The self-assessment is to begin 18 months into the health care organization’s three-year accreditation cycle.

A health care organization that determines it is not in compliance with one or more standards must work with JCAHO to develop a corrective action plan that addresses the shortcomings.

JCAHO will allow three to six months for completion of the self-assessment and development of the corrective action plan. During the onsite survey at the end of the three-year accreditation cycle, JCAHO surveyors will verify that the corrective actions have been implemented.

Introducing "tracer methodology." Using active patient files, JCAHO surveyors will randomly select one patient chart and trace that person’s path through the health care organization.

During this part of the survey, "all the questions are coming from the chart of a patient who actually received the care," said Russell Massaro, JCAHO executive vice president for accreditation operations. "We ask about what actually occurred to a patient, and we interpret those responses in terms of our standards," he added.

The surveyors will study the services provided to the patient, such as laboratory tests, drug therapy and monitoring, and other types of care received during the episode of care. Surveyors will speak with the health care professionals who cared for the patient and may also review organizational policies that affected the patient’s care.

William T. Richardson, chief executive officer of 191-bed Tift Regional Medical Center in Tifton, Georgia, said that the benefits the tracer methodology became apparent to his staff when Tift underwent a mock accreditation survey as part of a JCAHO pilot project. "The impact of the standards on the patients as they progress through the health care system is much clearer now to me and my entire staff," he said.

Narrowing the focus. JCAHO will continue to collect Oryx data from accredited organizations. This information, which reflects a health care organization’s performance related to specific outcomes of patient care, will be combined with additional data from JCAHO and other sources, such as the Centers for Medicare & Medicaid Services, and used to identify critical patient care areas that will be examined during the survey.

For example, JCAHO might determine from Oryx and other data that an institution treats a large number of elderly patients. In this case, the surveyors might pay special attention to examining medication monitoring and the prevention of falls—issues likely to affect hospitalized seniors.

JCAHO calls the tailored use of health care data the "priority focus process" and says the procedure will make each survey fit the individual circumstances of the institutions that seek accreditation.

Solving the mystery. JCAHO plans to present its revised standards in a new format that clarifies the things organizations must do to comply with the standards. In place of "intent" statements, JCAHO will use "elements of performance" that list the requirements for compliance.

Under JCAHO’s old format for standards, O’Leary said, health care organizations "were not sure exactly what the surveyors were looking at and how they were being scored for their compliance with standards." With the new format, he added, "It’s all transparent. You know what the standard is, you know what we’re trying to get at, and you know exactly what the surveyors are looking for."

Timeline. JCAHO’s new survey process goes into effect January 2004 for hospitals; laboratories; and ambulatory, behavioral health, home, and long-term care organizations.

Organizations due to be surveyed beginning July 2005 will receive the self-assessment tool during or after July 2003 and must then begin the self-assessment process. Previously accredited organizations that are due to be surveyed before July 2005 will receive the self-assessment tool for planning purposes but will not be required to submit it at that time.

Surveying the Surveyors

As part of the revamping of the accreditation process, JCAHO determined that surveyors, like health care organizations, need to be held accountable to standards.

This past January, JCAHO implemented a certification process that all surveyors must complete before actively participating in accreditation surveys. Surveyors are allowed three attempts to achieve certification. Those who fail to pass after three tries cannot perform surveys for JCAHO.

"The Joint Commission believes that skillbuilding and maintenance in the surveyor cadre is the key to realizing the potential benefits of the new survey design," said Russell Massaro, JCAHO executive vice president for accreditation operations.

Through the certification process, JCAHO hopes to ensure that the interpretation of each organization’s compliance with standards is consistent, no matter who conducts the survey.