Surviving your first Joint Commission survey
For many, a JCAHO survey is as enjoyed and anticipated with as much enthusiasm as getting a crown or filing taxes. While some health care organizations enjoy an advanced notice, most are caught unawares every couple of years with a smiling JCAHO representative at their doorstep, clipboard in hand. The fact of the matter is that JCAHO is not only there to perform an audit to assess the quality and safety of an organization’s patients’ care, but to suggest real world guidance to raise the bar of care provided. So if welcomed honestly and with an open mind, a JCAHO audit provides a great opportunity to assess and improve an organization’s health care quality.
At the core of a Joint Commission survey is the Tracer Methodology, starting with a selected patient/resident/client’s record to move through the organization to assess compliance with standards and to assess the organization’s ability to provide safe, quality-driven care and services. For each trace (of which a dozen or so may be performed), the surveyor will look for compliance with standards and educate leadership along the way with opportunities for improvement, frequently describing best practices found at similar health care organizations. If necessary, the surveyor will issue a Requirement for Improvement which must be addressed within 45 days, along with a four-month follow-up by the health care organization to prove sustained improvement.
During a trace, the JCAHO surveyor will ask to speak with staff involved with the selected patient’s care and treatment. This isn’t the chance to sweep things under the rug, but to be honest about the organization’s care and processes to maximize the gain from the survey. A staff member who is approached by a JCAHO surveyor should keep the following in mind:
- Answer questions directly and concisely.
- Answer questions honestly. If the answer isn’t known, don’t make something up!
- When possible, refer to specific internal policies and procedures, or real-world examples to demonstrate the quality of care described.
- Avoid getting defensive or upset – work to keep a mindset of becoming a better caregiver.
- Above all else, be polite, patient, and show enthusiasm for the care provided.
When interviewing each staff member, the JCAHO surveyor is trying to evaluate the staff member’s competency in their role, how care is coordinated, and if the staff member is familiar with policies and procedures, such as what to do in an emergency. Ultimately, it is the health care organization’s responsibility to ensure that each staff member meets the necessary competencies when these areas are assessed. Accordingly, as a first step, the organization should focus on the knowledge and preparedness of each staff member; specifically:
- Do they clearly understand their role in patient safety as pertains to the Joint Commission National Patient Safety Goals (NPSG)?
- Are they able to explain what makes them competent in their role and how their onboarding orientation prepared them? E.g., certifications, licensure, vaccinations and annual requirements.
- Do they know what procedures are in place for the ongoing improvement of patient care and safety?
- Do they know how to complete and review charts to determine if the assessment/reassessment is complete, if all entries are dated and authenticated, if handoff is documented, if the patient’s advance directive is clear, and if abbreviations are properly used (or avoided)?
- Can they explain how their responsibility of care is coordinated with other staff and units?
- Do they know what the policies and procedures are for dealing with emergencies (e.g., such as a fire or infection outbreak), code alerts, drug reactions, event/near-miss reporting and patient assessment?
- Do they understand how the Tracer Methodology works?
With proper planning and preparedness, a JCAHO survey isn’t a dreaded audit, but an opportunity to gain insight on how the organization’s quality of care and patient safety can be improved, not only for future surveys, but for the core goal of improving the patient experience and care.