Example of an Unannounced JCAHO Site Visit

1
Example of an Unannounced JCAHO Site Visit

• George Mason University
• College of Nursing and Health Science
• Regulatory Requirements for Health Systems
• Summer 2004

2
Setting

• Approximately 5 of surveyed organizations are
  selected for random unannounced surveys between 9
  and 30 months following their triennial survey.
• Performance areas to focus on during the random
  unannounced surveys are identified annually based
  on frequent type I recommendations, complaints,
  and sentinel event statistics.

3
What happened . . .

• A single surveyor presented to Administration at
  800 A.M.
• She provided a letter listing the areas for
  review and a tentative schedule for the survey.

4
Areas of focus

• IC Surveillance, Prevention, and Control of
  Infections
• PE Initial Assessment
• LD Role in Improving Performance
• TX Medication Use
• HR Human Resource Planning

5
Other areas for review

• Previous accreditation survey findings
• Compliant or sentinel event information
• Other information (i.e. CMS plans of correction)

6
The agenda

• 815 Opening Briefing
• 830 Tour of Emergency Department
• 930 Review of Documents Requested
• Statement of conditions updated from last survey
• Staffing Effectiveness indictors and analysis
• List alphabetically of personnel with data of
  hire and job title including any agency staff
• Policies related to National Patient Safety Goals
  and any monitoring
• Infection Control Meeting minutes and handouts
  since the last survey
• FMEA (Failure Mode and Effect Analysis)
• Definition of Sentinel Event
• 1045 Tour of Patient Care Areas
• 1230 Working Lunch
• 100 Tour of Pharmacy Area
• 145 Tour of Patient Care Areas
• 245 Review of Personnel Files
• 330 Surveyor Integration Time
• 430 Tentative Exit Briefing

7
Points of interest

• The surveyor spent a significant amount of time
  on the National Patient Safety Goals.
• She talked with the staff in each area she
  visited and reviewed documentation.

8
Exit conference feedback compliments

• Nursing assessment was good in the records
  reviewed
• Infection Control program was good
• The FMEAs completed and in progress looked good
  comprehensive and integrated to include Medical
  Staff
• Organization takes the sentinel event alerts
  serious
• The improvement in the timely completion of
  performance evaluations was also noted

9
Exit conference feedback opportunity to improve

• Implementation of National Patient Safety Goals
  to include the patient identification with two
  identifiers, do not use abbreviations, site
  marking and the pre-procedure pause.