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In 1913, the American College of Surgeons was put in charge of assuring that hospitals met minimal standards of care. At the time no hospital could do that. They developed standards that hospitals had to meet. By 1951 3,000 hospitals were accredited by them though they could barely meet the minimum of the standards. In 1951 this Hospital Standardization Program became the Joint Commission on Accreditation of Hospitals. They initially used the ANS standards. They are now succeeded by the Joint Commission on Accreditation of Healthcare Organizations. For many years everyone knew when the Joint Commission was coming to do a survey and the preparation was extensive. However, now the Joint Commission makes unscheduled visits in hopes that there will be an effort to be continuously ready and the quality of healthcare will be that good all of the time (McLaughlin & Kaluzny, 2006). This paper will discuss the methods being used for continuous readiness.
Preparation for the Joint Commission must be done in such a way as to maintain continual interest by the staff, maintain quality, provide history for new policies and keep the hospital prepared (Groper, 1999). This means that those of us that manage must also try to be inspirational and try to keep it interesting. Many hospitals have tried many different ways to do that. It is a serious enterprise because losing one’s accreditation is serious but it can also be fun and interesting.
One hospital in Vermont had different kinds of contests all over the hospital. These included huge crossword puzzles and survival games. In each of the contests, there was a need to answer the questions that JCAHO normally asks and get them correct to survive. The prizes were fairly simple such as lunch coupons, special parking space. They did quite well when JCAHO did show up and so they have continued their survival game as a continuous readiness method (Walter, 2002).
St. Joseph Hospital in Atlanta Georgia was the first health organization in the United States to go through the unannounced survey. It happened in February of 2004. The survey went very well and the staff came away from it feeling like the new process was much better than the old and more relevant to patient care. This, of course, included the tracer process (Comeau & Lowry, 2005). The tracer process is the process that many hospitals have adopted to provide for continuous readiness (Thompson, Pool, & Brown, 2008).
Having tracers done at least once a month has been successful too many. This entails assigning teams to pick up a patient’s chart and follow it through the care process looking at all of the things that are important for the survey. They usually carry a group of questions to ask, also that are questions that the Joint may well ask the staff. These teams are asked to keep their eyes open and be aware of things such as medication drawers open, carts left alone, unlabeled medication, ceiling and floor tiles in disrepair, charts open where patients or visitors might see them and computer screens turned so visitors might see the information you are placing there. They also ask questions such as what to do in a fire, what about nursery abduction, what to do with patients if there is a fire down the hall as well as many more questions. By doing this, the information is kept in the front of the staff’s mind and they are more ready to answer when JCAHO arrives.
There is a nice side effect to this preparation. As those teams are doing tracers, they automatically find issues with processes and policies that do not work well or that the staff does not understand (Murphy, 2006). This allows fixing those things, which provides for continuous quality improvement.
In conclusion, people have been frightened in the past about Joint Commission visits because of the ramifications of losing one’s accreditation. However, the Commission has done a nice job of updating in such a way that they are more relevant to the present care situation. The unannounced surveys provide for the opportunity to be continually ready and therefore have continual quality. This is what it should have been about all along.
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Comeau, E. & Lowry, D. (2005). Unannounced JCAHO survey. Journal of Nursing Care Quality. 20(1). 5-8.
Gropper EI. (1999). Expect truly unannounced surveys and more from the Joint Commission. Nursing Management. 30(10).
McLaughlin C., & Kaluzny A. (2006). Continuous Quality Improvement in Health Care. 3rd ed. Jones and Bartlett: Boston.
Murphy S. (2006). Nurses and the Joint Commission unannounced survey process. Journal of Nursing Care Quality. 21(3). 203-5.
Thompson EM, Pool S., Brown D. etal. JCAHO preparation and educational plans. Journal of Continuing Education in Nursing. 39(5). 225-7.
Walter, M. (2002). Fun with JCAHO. Vermont Nurse Connection. 3(4).