Experts share what to expect, how to prepare, and how to stay sane in a state of continuous compliance
With the new surprise survey process, you have to let the chips fall where they may,” explains Gregg Perry, CHSP, clinical engineer at Merrimack Valley Hospital in Haverhill, Mass.
Perry is referring, of course, to the change implemented January 1, 2006, when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began surprise visits, no longer going by appointment. News of this program leaked out of the JCAHO as early as 1998, and in 2004, the accrediting body started the arduous process of pilot-testing and fine-tuning the unannounced survey program at volunteer hospitals.
By this past January, the Centers for Medicare and Medicaid Services ordered every accreditation survey to become an unannounced survey—a change that has caused more than a ripple of concern in hospital clinical engineering departments and throughout the entire hospital.
Yet Perry is quick to point out that this survey is quite an improvement over the previously scheduled visits. Though the 140-bed hospital passed its accreditation survey in January, the survey came nearly 4 months before expected. “One good thing is that you don’t get an ulcer for 3 months from nonstop preparation. With the secret attack, they saw us as we really were, and the best part is that it’s over, it’s painless, and you are what you are.
“The difference from any past survey was that this time, the survey was completed as an actual survey—unannounced, the right way it should be done. It was done properly because we didn’t know they were coming.”
In fact, between January 1 and April 30, the JCAHO conducted 1,860 surprise visits, according to Janet McIntyre, a JCAHO spokesperson. These surprise surveys, part of the Shared Visions-New Pathways program, are meant to focus on patient safety. And experts agree that as long as policies and procedures are kept up to date, there should not be an issue.
A Shared Vision for Patient Safety
So what is the Shared Visions-New Pathways program? Essentially, it shifts the focus from survey preparation to continuous improvement. The JCAHO’s hope, of course, is that unannounced surveys will create an expectation that each accredited organization is constantly in compliance with 100% of necessary standards.
“The process of the unannounced survey takes people by surprise. What the JCAHO is saying is, ‘We want staff to be prepared all the time, because patients show up at the hospital all the time.’ This new survey is really a patient-safety issue,” says Sam Fager, MD, JD, MBA. “In the past, hospitals knew survey dates in advance and could easily schedule vacations or conferences, but now there is some uncertainty. What the JCAHO really wants to see is how a hospital functions all the time.”
If anyone would know about potential survey glitches and how to avoid them, Fager is a certified expert. A JCAHO surveyor in the Freestanding Ambulatory Care and Hospital Accreditation Programs from 1986 to 2005, he was part of a task force to help launch and implement the new survey process. He now works as the chief medical adviser and board member for Equipsystems in Brooklyn, NY, an equipment-management solutions company that helps hospitals manage and prolong the life of patient-care equipment.
With JCAHO’s tracer-methodology program, it means, more specifically, that the surveyor will want to see equipment- management systems in place. Fager stresses that with tracer methodology, the focus is literally on “tracing” a patient’s experience in the environment of care. A biomed department can anticipate how the tracer methodology will work by establishing its own protocols for how to track patients whose treatments involve the use of medical equipment. For example, if a surveyor has chosen a patient record that shows past examinations with a particular defibrillator, the surveyor may request to see the maintenance log for that piece of equipment. Fager says the surveyor may write down the number on the equipment and then look through your schedule of maintenance. If the surveyor notices any glitches, there is going to be more investigation.
Fager explains that the new survey process is all about inductive reasoning versus deductive reasoning. For example, the inspectors are not just checking items off of a list; instead, they are searching for any breaks in continuity in the care that could potentially cause patients harm.
“It’s now very easy for hospital workers to understand the survey process. Before, standards were more distant. Now, having tracers throughout means that a surveyor goes to look at a patient’s chart and discusses how the care of that patient may or may not be in accord with standards,” he says. “One of the nicest things I noticed back in 2004 was staff saying, ‘This makes sense, this process makes a great deal of sense!’ They were happy to see that what they do now relates back to standards.”
In his consulting work, Fager says that he often sees management plans that are not comprehensive, including organizations forgetting to include something as important as the off-site ambulatory area. To avoid a similar mishap in your biomed department, Fager suggests the following four “insider” tips:
uStay aware of all areas. Though ambulatory areas are the areas most likely to be missed, it is equally imperative to remember to include new sites, other off-site locations, or contract services in your equipment-management plan. Make sure that if it is out of sight, it is not out of mind.
uFocus on education. Although it may seem daunting, given your hectic work schedule, take the time to become acquainted with what JCAHO standards are included in the survey so that you do not stare blankly when the surveyor poses a difficult question.
uCommunicate effectively. Work with hospital administration to verify the entire scope of the survey. Be mindful of your paper trail, and remember that preparation and communication with others could make or break your department come survey day.
uAct out. Fager sees some hospitals performing a mock survey every month, depending on the size of the organization. A mock survey may help staff understand how the group can come together, he advises. Write down sample responses that emphasize strategic areas of your management plan, preparation you will cherish if a surveyor tries to throw you a curveball.
Is Your Contingency Plan in Place?
Do all of your technicians know what the surveyor will be looking for in case you are not there? Can you fill your continuous quality improvement (CQI) director’s shoes in case he or she is absent? Are you prepared for the unexpected?
Take the case of Salem Community Hospital in Salem, Ohio. The regular interval for surveys was in June or July—but the JCAHO surprised the 237-bed nonprofit hospital by showing up 3 months early, in March.
“Everything went well, but it is definitely different. Now, they walk in and say, ‘Surprise, here we are!’ The announcement was made at 7 am, and they showed up at 9 am,” says Jerry Wheeler, CBET, biomedical/communications manager.
In fact, not only was the hospital not expecting a survey that week, its CQI director—who accompanies the surveyor and serves as the main liaison—was vacationing in the Florida Keys. The CQI director returned by the last day of the 3-day surprise survey, and she commended the staff who, even in her absence, were able to maintain a high level of professionalism for the surveyor.
Wheeler explains that the surveyor might request to see contracts for outside vendors, such as for computed tomography scans, and will want to see that their records match your records. “It was very thorough. I felt good we had everything,” he says. “For user error and how we track it, she wanted to identify an area where we found a problem. She asked, ‘How exactly did you take care of this?’ Then, she requested the supporting paperwork to ensure the dates matched up.”
Tracer methodology could hit you from any angle, Wheeler warns. For example, he relates how he was asked about preventive maintenance for the blood/fluid warmer equipment when the surveyor noticed Wheeler was performing the task quarterly. When she asked about the discrepancy between the manufacturer’s recommendation of an annual inspection and the report in front of her, Wheeler replied the quarterly report satisfies the American Blood Bank Association requirements.
“This response made the surveyor very happy, because it’s important to always have a response to a question. Always anticipate what a surveyor might ask, rather than answering ‘I don’t know’ or something,” Wheeler advises.
His biggest piece of advice, however, is to institute a monthly audit. “Before the survey, there had been a few things I had been meaning to get to and had been planning on reviewing, but it just didn’t happen. I was very lucky that the surveyor never touched upon those issues,” he says. “After the survey, I decided to start doing a monthly audit. Make sure your technicians can easily walk the surveyor through the process. It’s not a bad idea to share audit responsibilities and to keep everyone current.”
For example, if there are four or five employees in the biomed department, the manager could delegate the audit responsibilities monthly, ensuring that each person gets an ongoing chance to stay current, informed, and prepared for survey day.
What are Wheeler’s final words of wisdom to ensure smooth sailing when survey time arrives? “Make sure, especially if you’re a small hospital, not to put your eggs in one basket,” he says.
Surveyors could show up at any time, he warns, so the biomed department needs to have an ongoing awareness of all documents so that a variety of staff in the hospital can explain them well enough. Be sure to cross-train a variety of people, sharing the information with technicians as well as hospital administrators. Prep-aration and communication are key, he advises, so be sure to designate who will be able to stand in for cross-coverage.
Elaine Rigoli is a contributing writer for 24×7.