Coping with JCAHO changes

From HMCwiki

This year more than ever, every organization needs a plan for coping with JCAHO changes. Several changes have been implemented to the survey process in rapid succession, and facilities are feeling the crush; Recommendations for Improvement (RFIs) are up.

1 JCAHO's double-whammy
2 The six-week scramble
3 A third whammy?
4 Additional information
5 Related links

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JCAHO's double-whammy

JCAHO has recently made some major changes to their survey process, in effect creating a "double whammy" for hospitals that haven't had a survey in some time. The first change is the use of "Tracer Methodology".

The Tracer Methodology involves the selection of a patient that the Surveyers "trace" throughout the organization to check for compliance with current guidelines. Surveyer speaks to nurses, radiology technicians, labratory technicians, and other front-line service providers - as opposed to reviewing information provided by a Management team.

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The six-week scramble

Time was when some hospitals would begin planning for their JCAHO survey six weeks prior to the event, scrambling to ensure that all requirements were being met. But with the new implementation in February 2006 of unplanned surveys, the last-minute scramble is a thing of the past.

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A third whammy?

In the summer of 2004, the government released a report with the catchy title of "Medicare: CMS Needs Additional Authority to Adequately Oversee Patient Safety in Hospitals". (See highlights of this article). The report had some bad news for JCAHO, suggesting that they were not doing their job - to assure patient safety. Apparently, soon after some institutions passed JCAHO's survey with flying colors, government inspections uncovered patient safety violations. The report called for additional oversight by CMS. JCAHO denied these findings, saying that they had experience similar situations (where a state agency approved a hospital yet JCAHO found problems) and that they had not been using their new Tracer Methodology at the time. Congress took no action on the report, but the possibility that JCAHO's position could be usurped by CMS remains.

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Additional information

Learn more or share your experiences at preparing for an unannounced JCAHO survey.
Reveiw our JCAHO surveys by department section to find or add your department-specific experiences with JCAHO.

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