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JCAHO Moves to 'Unannounced' Surveys for Everyone

Donna Young

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced last week that, beginning in January 2006, all regular accreditation surveys will be conducted without announcing the dates of the forthcoming visit.

Darryl S. Rich, JCAHO’s associate director of surveyor management and development, said the "unannounced survey" process will be tested in 2004 at 100 organizations that have volunteered to try the new process, starting with Children’s Memorial Hospital of Chicago.

Four health systems, including Ascension Health, Tenet Healthcare, North Shore–Long Island Jewish Health System, and the Veterans Health Administration, have agreed for several of their facilities to test the process in 2004 and 2005. JCAHO will then open the unannounced survey process to a limited number of health care organizations, on a voluntary basis, in 2005.

Rich said the unannounced survey is part of JCAHO’s new accreditation process, Shared Visions–New Pathways, which begins in January 2004 and uses new medication management standards.

Under the new process, he noted, health care organizations must complete a periodic performance review, formerly referred to as a self-assessment. The performance review is intended to help organizations identify noncompliance with JCAHO standards and provide those organizations an opportunity to develop a corrective action plan, he said.

When the self-assessment was first announced last fall, Rich noted, some organizations misinterpreted the concept and assumed that it replaced part of the on-site survey process.

But, he said, the performance review precedes the survey process and gives organizations time to "fix things so that when we go out there, hopefully there’s nothing wrong with the organization when we are looking at it."

Organizations are required to complete their periodic performance review and corrective action plans, if any, by the 18-month point in their accreditation cycle, according to JCAHO. However, Rich said, that timeline could change because of the new unannounced survey process. JCAHO will provide more details about performance review as the unannounced survey process moves forward, he added.

Rich is scheduled to speak June 3 at ASHP’s 2003 Summer Meeting in San Diego, where he will discuss "in detail" JCAHO’s new medication management standards, he said.

Clinicians can electronically access a prepublication version of the standards through their JCAHO extranet connection starting June 15.

The medication management standards will officially be made available as part of the 2004 Comprehensive Accreditation Manual for Hospitals (CAMH), scheduled for release in September. Each accredited hospital will receive a copy of the 2003 CAMH, Rich said.

The standards will also be available in the 2004 Hospital Accreditation Standards book, which must be purchased, unlike CAMH, and is scheduled for release in November.

The medication management standards are "significantly different than the draft standards" Rich said, and "are a lot more prescriptive."

"Some people are doing everything that’s in them right now, and others are going to have trouble getting in compliance with them," he said.

Clinicians had sent JCAHO more than 1,100 comments about the draft standards, he said. Focus groups and JCAHO’s Professional and Technical Advisory Committee also provided feedback, he added.

JCAHO also announced last week that, beginning in January 2004, it will prohibit part-time surveyors from acting as consultants on accreditation-related issues for health care organizations.

Full-time surveyors, Rich said, have always been prohibited from serving as consultants about accreditation requirements.

The prohibition does not prevent part-time surveyors from serving as consultants to health care organizations regarding financial and marketing issues unrelated to JCAHO standards or the accreditation process, Rich said.

But with JCAHO’s new unannounced survey process, Rich said, the need for consultants will decrease, and organizations can save money. 

"The whole concept of preparing for a survey is going away," he said. "If you don’t know when we are coming, how can you prepare other than by being in compliance all the time? The whole goal here is for patient safety, and that is what we are trying to do ... push so that the incentives are there and ... the organization is doing the right things to improve safety."

The "real cultural change" and "biggest challenge" for organizations under the new accreditation process, Rich said, is the shift to a pass-or-fail scoring system from the previous points-based system.

Also effective in January 2004, as part of Shared Visions–New Pathways, is JCAHO’s revised and reformatted "Management of Information" under the Standards Review Project for hospitals, laboratories, and other health care organizations, including those providing home health care. Some new requirements have been added to highlight changes created by the emerging electronic environment and to emphasize some of the provisions in the Health Insurance Portability and Accountability Act of 1996 relating specifically to patients' rights, according to JCAHO.

New health care error-reduction and patient safety standards for 2004 will appear in the Comprehensive Accreditation Manual for Home Care.