For three biomeds, the new survey process proves easier done than said.

 Some biomed department leaders confess they were expecting the worst when their turn arrived to experience the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) new survey methodology, implemented nationally at the start of 2004. However, their dread over Shared Visions—New Pathways proved unfounded.

“Our accreditation site visit was actually a smoother process this time around,” says Ronald D. Snodgrass, CBET, manager of clinical engineering at EMH Regional Medical Center in Elyria, Ohio, whose institution underwent inspection this past summer. “I was asked all of maybe five questions, half as many as I had to respond to in 2001.”

Jerry Messina, director of biomedical engineering at Louisiana State University (LSU) Health Sciences Center in Shreveport, is another who anticipated a tough row to hoe because of “Shared Visions” but experienced something entirely different.

“All in all, it went well,” he says. “It was not anywhere near as bad as I thought it would be. I previously worked in the Veterans Administration hospital system where we had these very, very intense surveys. That got me accustomed to being asked a lot of highly technical questions and having to produce a lot of richly detailed equipment histories. I was expecting that to be the kind of thing we’d run up against in the Joint Commission’s new process. To the contrary, the surveyor didn’t hit us with much of that because this time he was more focused on talking to the patient care teams about clinical matters.”

Mark Melvin, CBET, biomedical equipment technician at Marian Community Hospital, Carbondale, Pa, felt a twinge of disappointment when the survey showed itself to be less than grueling.

“It was almost a letdown,” he says, half-joking. “We were ready like prizefighters heading into a championship bout against a formidable opponent. We figured we’d go a full 10 rounds, not see the fight over in round one.”

Melvin says he was scheduled to meet with the JCAHO surveyor as part of a group of representatives from several other departments. Ninety minutes had been allotted for the encounter; Melvin says the meeting lasted half that long.

“Since everyone had their own opinion of what would be asked, we all went overboard with our preparations—hoping to cover everything that possibly could be asked,” he says. “We did way more than we needed to.”

Tell, Don’t Show
The Joint Commission visit to Melvin’s hospital occurred in mid-September. With that survey, Melvin could dub himself a veteran of five such accreditation inspections over the course of his career.

“Going by my past experiences, I was of the opinion that in biomed we needed to gear up for the survey by first reviewing and fine-tuning our policy and procedure manuals,” he says. “We also decided it would be wise a few days before the visit to walk through the facility and check for medical devices lacking stickers or with stickers that were outdated. We found a couple of slipups, but, on the whole, not bad.”

Melvin says that the majority of preparations were devoted to addressing JCAHO safety goals 5 and 6.

“Preparing for goal 5—‘Improve the safety of using infusion pumps’—was relatively easy since we’re only a small, 114-bed hospital,” he says. “Of our 100 or so infusion devices, just three were found to have free-flow issues. Fortunately, these had been removed from service months earlier.

“We weren’t so lucky with goal 6, ‘Improve the effectiveness of clinical alarm systems.’ Since that goal was new for 2004 and seemed to us slightly vague, we spent a lot of time trying to decide what we should do. Or, to be more accurate, what we thought the Joint Commission wanted us to do. So, we formed a work group to decipher the goal. Nursing, legal affairs, and biomedical engineering—with an assist from the Biomedtalk Listserv—together hashed out what we thought was an acceptable game plan. We made the appropriate policy changes and implemented our plan.”

Then came the site visit. The surveyor was a nurse administrator. He stunned Melvin by not posing any questions on device alarms.

In all fairness, Melvin was not asked about alarms because the surveyor already knew the answers. He had obtained them earlier by talking to clinicians on the floors.

Still, it was mystifying to Melvin that he was not directly quizzed on those alarms—or, for that matter, asked any questions about a number of other aspects regarding the biomed department’s contributions to quality at Marian Community Hospital.

“Three years ago, in our last accreditation renewal, the surveyor was insisting on seeing trend information in bar-graph and other pictorial forms,” Melvin says. “So, figuring that’s what they’d want this time, we went to a lot of effort to produce trending data in chart form—maybe 30 or 40 pages’ worth. On top of that, for my meeting with the surveyor, I brought a good 30 lbs of policy-procedure manuals, PM status reports, a compliance manual, the whole nine yards. I even had to use a tool cart to wheel it all up to where the surveyor meeting was.

“But the Joint Commission didn’t ask for any of that at all this time. I wasn’t asked to produce so much as a single document by the surveyor. I guess that wasn’t necessary because he’d reviewed a lot of the general biomed-related materials from other sources, such as the hospital’s safety officer.”

The surveyor did, however, express interest in performance improvements initiatives for each of the seven Shared Pathways environment-of-care sections. Even at that, though, he did not want to be shown reports, Melvin says. “The surveyor simply wanted to hear about what we were doing,” he says.

Melvin adds that he was somewhat shaken by having to deliver, at the surveyor’s request, an impromptu oral presentation about the department’s activities.

“I’m not much of a public speaker, so this really got me jumpy,” he says. “I was afraid this was going to be one of those situations where they purposely make you nervous.” But instead of losing sight of his talking points and misspeaking, Melvin maintained his composure and said just what needed to be said.

“I received a bit of a break by not having to be the first one to talk,” he says. “That gave me a few moments to quickly jot down some thoughts—old standbys like PM completion rates, unable to locates, in uses, and mean time between failures.”

As soon as Melvin wrapped up his chat, “the surveyor looked me in the eye, gave me a thumbs-up, and said, ‘you pass.’ ” Three weeks later, the Marian Community Hospital received word it too had passed.

 Ronald D. Snodgrass, CBET, of the recently JCAHO-inspected EMH Regional Medical Center, checks the voltages of an ultrasound unit.

Acquitted Himself Well
Snodgrass relays a similar tale, but says that the curve thrown to him involved having to speak to the surveyor about 48 hours ahead of schedule.

By Snodgrass’s reckoning, his meeting with the surveyor would not have arrived until day four of the site visit. Instead, to his dismay, he was summoned for that confab on day two.

“Our director of perioperative services had been asked questions about maintenance of the equipment in the dialysis unit; she wanted me to be there to respond, feeling I’d be able to offer better informed answers,” he recounts.

Snodgrass acquitted himself well, but afterward realized how easy it would have been to trip over his own tongue since he was not as well-rehearsed for a discussion of dialysis equipment maintenance issues as he was of other topics—owing to the fact that the hospital had years earlier outsourced its entire dialysis program to a third-party provider.

“I spent time preparing mostly to respond to the patient safety goals described in the Joint Commission materials given to us before the surveyor visit,” he says. “These indicated that clinical engineering was responsible for clinical alarm inventory, the testing of clinical alarm systems in the hospital, making sure the IV pumps had free-flow protection. But the effort I put into these areas turned out to be moot because I wasn’t asked any questions with regard to them.”

Snodgrass estimates that three quarters of the questions pitched during the environment-of-care session pertained to safety management. “Only about 20% had anything to do with medical equipment management,” he says.

During preparation for the visit, a big concern for Snodgrass was the whereabouts of several misplaced infusion pumps. “My hospital has more than 300 infusion pumps and some of those were unaccounted for,” he says. “I didn’t want a situation where the surveyor would be touring the facility, open a closet for a peek inside, find one of our nonlocatable pumps sitting there, and then demand an explanation of why it missed its last PM.”

Snodgrass solved the problem by arranging to reward the housekeeping staff with a free meal worth $6 in the hospital’s cafeteria for every missing pump they hunted down and turned in. “Basically,” he explains, “we asked housekeeping to notify us of any pump found with a date label showing it overdue for a PM, or with a label rendered illegible from prolonged exposure to cleaning agents, or that had been borrowed from our sister hospital as denoted by its colored tag.”

The incentive resulted in the retrieval of 25 pumps. One sleuthing housekeeper single-handedly delivered more than 15 (and ate on the house for the next few weeks).

Knowledgeable Surveyor
One of the most impressive aspects of JCAHO’s new process, according to LSU’s Messina, was the surveyor’s greater level of biomed knowledge.

“This individual was very familiar with the different methodologies of performing equipment maintenance,” Messina says. “I had only to mention which methodology we were using and he understood what that implied and how it worked.”

Notably, the surveyor was not a biomed by profession, but rather someone employed in an administrative capacity.

Messina’s encounter with him occurred in the confines of a conference room; attending along with Messina were representatives from several environment of care–related departments. Messina came to that meeting with an armload of dog-and-pony show materials. These included a copy of the hospital’s equipment management plan, the biomedical engineering department’s policies and procedures, equipment-active inventory, a rundown of performance-improvement activities, a list of the intents of the standards, and an explanation of how the department was meeting those standards. Also supplied were sample history reports and repair-cost analyses run by biomed for some of the clinical departments. Together, these materials took up approximately 150 pages.

Messina was grateful he did not have to stand in front of the group and make a formal presentation. However, he was surprised that the surveyor did not request to see even one of the printed materials Messina brought.

“That was because he already had in his possession a copy of the equipment management plan,” Messina says. “He’d obviously already read through it. I was sitting right next to him and noticed he’d had several pages of it bookmarked and highlighted.”

Working off those pages, the surveyor directed a mere three questions at Messina. The queries were right to the point.

“He wanted to know if our equipment management plan was risk-based. It was. He then wanted me to define what was meant by risk-based,” Messina says. “He also wanted to know if we documented our periodic maintenance and how.”

Messina spent about 45 minutes talking to the surveyor—after having devoted an average of half an hour a day for 6 months to getting ready for inspection (and up to 2 hours a day in the final 2 weeks immediately prior to the visit). Still, Messina is convinced the effort was worthwhile and did not represent overkill.“We were ready for anything they could throw at us,” he says. “Far better to be overprepared for something as important as this than underprepared, although I think next time I won’t produce quite as elaborate a dog-and-pony show.”

New Accreditation Process Emphasizes Performance
The Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) Shared Visions—New Pathways was unveiled in late 2002 for pilot testing and then rolled out nationwide at the start of 2004.

The big change wrought by Shared Visions finds surveyors focusing on actual delivery of care rather than on policies and procedures.

“We’re evaluating services from the perspective of the patient,” Carol Gilhooley, director of accreditation process improvement for JCAHO, told 24×7 a year ago.

Gilhooley indicated back then that a surveyor might do things like pick at random a patient chart, determine from it which departments interacted with the patient during his or her admission or encounter and then go talk to the personnel responsible for providing the services used by that patient.

“During pilot testing, organizations told us they appreciated this approach because it removed the emphasis on paperwork and instead placed it on the activities they do in the course of a day that contribute directly to the safe delivery of quality care,” she said.

Under the new guidelines, surveyors are tasked with drawing a spectrum of hospital personnel into discussions about medical equipment—specifically with regard to the risks they have identified apropos usage and maintenance.

JCAHO no longer provides raw-form information to surveyors. Instead, surveyors are aided by a decision-support tool known as the Priority Focus Process. In a nutshell, presurvey data collected on each organization from accreditation applications, statements of conditions, and other documents are crunched by a computer that automatically produces a list of potential problem areas for surveyors to focus on during their visits.

Gilhooley indicated this is meant to ensure process consistency and help eliminate surveyor bias, two major sources of complaint in years past. —RS

Rich Smith is a contributing writer for 24×7.