| Focus on the
New JCAHO Survey Process
The revolution
in JCAHO surveys is not just the “tracing” of a patient
through the facility. That’s the way we give care and has
always been at the crux of all mock surveys, reviews by other
surveyors such as CMS.
The gearing up process entails the “ever readiness” required
for the unannounced survey. This is the only survey style in
2006.
Get ready for a change!
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Changes Encountered
- Consider all the material that must be in place for a survey to commence.
Other state and federal regulators have taught us to compile documents
quickly, thus keep current versions on hand.
- Pay attention to the “logistics” of
managing a survey. Logistics end up being methods of notification,
communication and
sharing information.
- Planning for activities that keep survey readiness in front of
staff who are off doing their own duties is the challenge.
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| Methods and Tools
Success strategies are:
- Keep emergency lists current. Update the emergency notification
list, including both e-mail and text pagers.
- Use every opportunity
to improve the “surprise” factor.
When conducting disaster drills, identify improvements that will
impact the staff when a surprise surveyor is on site.
- Test the plan. Use a three
hour period of the day to drill the “unannounced” portion
of the survey. Do this test every six months.
- Create a policy for the “external survey process” including
the unannounced and imposter considerations.
- Always have the “Organizational Orientation” presentation
ready. Even if the Core Measures/ORYX data is a quarter
old, you at least have a current CD of your PI process, organization
and
community statements.
- Information Management interface. Do not take daily
census and surgical report creation for granted. Have
IT run reports
2-3 times per year
to be sure the process has not degraded with the transfer
of staff
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Lessons Learned
- Overall the unannounced
survey process is being touted as the “best” the
JCAHO has delivered. There is a sense of reality and authenticity that
rises above any experience of the previous “false bravado” encounters!
- Recognize pager dead zones. This is an improvement for all uses
of pagers.
- Managers need to keep up with technology and make the move from
numeric to text pagers.
- New managers need to be advised to get on the Emergency Notification
list.
- Debrief administration with what it will be like to manage
with only those who are present.
- Have practice sessions
with members of the leadership team, so they can role play the “Organizational Orientation” presentation.
- Have the surgical sites (OR, Endoscopy, Ambulatory Surgery)
review the IT data for assurance it is accurate.
- Don’t be compulsive about having every plan and policy at your
fingers. If you can find them in an hour, you’ll
be ready!
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