Dear Colleague Letter of Current Events

The tide in changing, the waves are larger, plant your feet on your surfboard and get ready for the ride! Unannounced JCAHO surveys are here to stay.

Unless your organization is one of the 200+ organizations that volunteered for an unannounced survey in 2004 and 2005, you will want to take some time to think out the “logistics” of your next survey.

Consider the time the survey coordinator must spend in survey preparation by 2006:

Annual Period Performance Reviews
Working through any plans of correction in the PPR, quickly
Budgeting for 1/3 of the JCAHO fees annually (which have gone up considerably!)
Application submission
Updating the Business Associate Agreement for HIPAA issues
Practicing tracer process, conducting mock surveys, and organizing “Logistics Training” for the new “surprise window” or first three hours the surveyors are on site
Staffing a “Command Center” that organizes the facility efforts, and supports the staging area set up for the surveyors. The “Command Center” will be the brain of your facility were all documents are gathered, reviewed, files assessed for completion and communication to staff originate.
Dealing with the recommendations for improvement (RFI) and designing the evidence of standards compliance (ESC) details.

All of this seems like a daunting task. This looks monumental if you have other duties, in addition to the survey coordinator role. However, I bring good news! This is doable. I have experienced this very process. In fact, once you get past 11:00 am the first morning of the survey, you’re home free!

Click here for some ideas on how to prepare for the critical three hour time frame. Consider the elements of “Logistical Training”. The JCAHO is very helpful this year. Your JCAHO Extranet access will provide you the “Survey Guide” at the Jayco website are essential free tools. Contact me if you feel you need other information, but you need to prepare now, even if you wave is not approaching until 2008. Be Prepared! The unannounced survey really means it!

Best wishes,

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Paula Swain
Swain & Associates

Last updated: August 23, 2005