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JCAHO surveyors will trace random patients through the hospital, every step of the way.


From Start to Finish
Hopkins Hospital drills for a new era of JCAHO accreditation surveys

It’s lunchtime on the adolescent unit as the surveyor, clipboard in hand and team in tow, arrives unannounced at the nursing desk. She identifies herself to the charge nurse, who is visibly alarmed. Dutifully, the nurse leads the surveyors into a conference room, where they pour through the chart of a teenage girl—chosen at random—and question her primary care nurse.

Is every page stamped with the patient’s name and hospital ID number? Are orders and signatures legible? How are verbal medication orders handled? Multidisciplinary care communicated?

The surveyors then trace the girl’s care back to the emergency department, where she initially arrived. In fact, they visit each area this patient has touched—radiology, pharmacy, social work—until they’ve audited the teen’s entire hospital stay.

This time, the “tracer” survey was for practice, one of a series of mock surveys that Joyce Jones, hospital JCAHO coordinator, and Ella Giles, the hospital’s new regulatory affairs coordinator, are leading to prepare for the real deal in November. That’s when, once again, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, commonly pronounced Jay-Co), the industry’s most powerful accrediting agency, will descend on East Baltimore, probing for evidence that the hospital is adhering to its strict standards for quality patient care.

Starting this year, however, the JCAHO survey will be noticeably different. It’s now based primarily on clinical and system tracing. Clinical tracing follows patient care; system tracing follows organizational processes like medication management and infection control. Both are based on the hospital stays of individual patients.

“Clinical documentation in the patient record will determine the clinical units and patient service areas to be visited,” says Jones. “The documentation is also what will give the surveyors a real idea of our understanding of quality patient care.” The new tracer method will shift the spotlight from managers and policy makers to staff who work directly with patients, she says. “It will allow them to examine the way protocols are ‘lived out’ by practitioners, instead of what administrators intended in theory.”

Both Bayview Medical Center and Howard County General Hospital recently passed their Joint Commission accreditation surveys with flying colors. (HCGH was surveyed using the new tracer process.) “But it’s only going to get tougher,” says Hopkins Hospital President Ron Peterson. In July, the Government Accountability Office (GAO) accused the commission of regularly missing serious patient safety problems, a charge JCAHO vehemently denied. In response to the negative publicity, Peterson predicted, “they’ll definitely tighten up their act.”

Each of the 16,000 health care organizations accredited by the Joint Commission actually volunteers to put itself through the rigors of the triennial survey. Why? Because JCAHO accreditation allows hospitals to receive Medicare reimbursements, and is required by virtually every managed care contract. The GAO report could eventually result in more government oversight of the private agency.

To help prepare the Hospital for the new survey style, Jones and Giles selected 25 experienced employees—from environmental services, nursing, laboratory services, even IT—to serve as mock surveyors. (Jones anticipates that the actual survey team will consist of about five people, who will trace as many as 40 to 50 patients.) After a day of classroom training, the group divided into teams and began participating in mock tracer surveys, led by Giles.

Just like the real thing, they choose patients at random and, using the chart and interviews, follow their care across the spectrum of their stay. They look for evidence of proper physician supervision of residents and care provided by a credentialed practitioner, good communication between disciplines, and timeliness of services. For the first time, they’re scanning for those unacceptable abbreviations in medication orders and seek to understand how each unit is adhering to the National Patient Safety Goals.

Through these goals, the Joint Commission is seeking to improve patient identification, communication among care givers, and medication safety, as well as eliminate wrong site/patient/procedure surgery and health-care-acquired infections. But care givers won’t be asked to simply parrot the list. Instead, they’ll be asked to tell how the unit is actively applying those rules to its practice: How does your unit identify a patient? How do you validate that the patient is getting the correct medication?

The mock tracer surveys began July 8 and will continue through the fall until the Joint Commission comes knocking on Nov. 15. This is the last time the surveyors will provide advance notice of their arrival. In the future, all JCAHO inspections will be unannounced.

Lindsay Roylance




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