Organizations seeking accreditation can also look at the standards identified as problematic among those organizations receiving a random unannounced survey. Every year, 5% of JCAHO accredited health care organizations undergo a random unannounced survey. An organization can be selected anytime between 9 and 30 months after its initial or triennial survey and will receive no advance notice.
(Note: Random unannounced surveys will cease in 2006.)
Performance areas reviewed during unannounced surveys typically focus on standard(s) receiving a high percentage of recommendations, sentinel event statistics, or issues of public concern. The areas of performance being reviewed in 2003 are:
1. Credentialing and privileging of licensed independent practitioners (Human Resources)
Tip: Make sure all credentialing criteria are verified prior to granting privileges (HR.7.1). Make sure appropriate verification of competency, training, and experience is conducted before granting privileges (HR.7.2.1).
2. Competence Assessment (Human Resources)
Tip: Make sure all competencies are defined for all positions and for all new hires prior to assigning them to perform duties. Identify competencies that need to be assessed on an ongoing basis, at a minimum of once within a 3-year accreditation cycle, for all positions. Conduct the assessments in accordance with the time frame your organization has established (HR.5).
3. Implementation (Environment of Care)
Tip: Tour your facility to search for possible safety hazards. For example: Is equipment in the hallways blocking the fire alarm? Are patient supplies being improperly stored under sinks? (EC.2.1)
4. Improving Performance (Performance Improvement)
Tip: Be sure to analyze and aggregate collected data. Do not just report statis- ticsanalyze what they mean. Consider using statistical tools such as run charts and Pareto charts to display data as a means of further analysis (PI.4).
5. Medication Use (Care of Patients)
Tip: Pay close attention to the 2003 National Patient Safety Goals that deal with patient identification and communication. Verify that you have the correct patient prior to administering any medication. Verify any and all verbal orders prior to administering medication by a read-back system.
According to JCAHO surveyor Norins, achieving success in performance areas that are stumbling blocks for some is as simple as remembering some lessons from school:
“As organizations prepare for survey, discuss how each standard is achieved system-wide. Is there variation in the how’ from one care site to another? Or from one day of the week to the next? Are there 12 ways of doing the same thing? Is this acceptable or not to the organization’s leadership?
“To help determine the how’ of each standard, consider answering the
5 W’s you learned in school: who, what, why, when, and where. Answering these questions will help determine if everyone within the organization shares a common understanding and is on the same page.”