Comments on: JCAHO – The Borg?

By: Mary Baker, MS, CPMSM, CPCS, CPHQ

Mary Baker, MS, CPMSM, CPCS, CPHQ — Sun, 01 Jan 2006 20:51:05 +0000

I have thought for a long time that unannounced surveys should be performed. I have been in the Medical Staff Services field for many years and have witnessed the facility trying to get ready (get things cleaned up) just before JCAHO comes in for the scheduled survey, only to go back to the bad habits (Temporary Privileges without verifying credentials is only one example).
It would serve us all (including medical staff, administrators, etc.) to remember who we are protecting….the patient, the public from the Michael Swango’s (and yes there are still some Michael Swango’s out there). It only takes one bad doctor for Medical Staff and Administration to question “How did this doctor get on staff and how do we get them out of our facility.”
Mary Baker, MS, CPCMS, CPCS, CPHQ
President
Medical Staff Plus Consulting, LLC

By: plb

plb — Fri, 23 Dec 2005 18:02:33 +0000

Been through JC surveys from healthcare admin perspective for many years. The ongoing readiness coupled with continuous improvement etc. vision makes sense from an operational standpoint to a certain point. However, the layering on of compliance standards, esp. the safety goals, are breaking the camel’s back. Like the drive for EMRs for healthcare, including small MD practicies and small community hospitals, the same expectations from JC for smaller hospitals is impractical and unrealistic. We can chase people (and facilities) from healthcare with this inordinate amount of standards that are approaching a checklist and audit for every step of care. There must be a better way. How can the same number of staff and a shrinking margin cope with all this?

By: CardioNP

CardioNP — Fri, 23 Dec 2005 01:14:26 +0000

I recently left a facility that volunteered for an unannounced survey last year. It was nearly a year of stress as everyone was thinking the survey was going to be “next month”. When the grapevine indicated that other local institutions were being surveyed, the mgt thought we were next. We weren’t.
So it was continual month after month of being told JCAHO is coming in the next couple weeks, and then they didn’t. IIRC, they ultimately came at the end of summer and I had the pleasure of not encountering any of the surveyors. So my guess is that unannounced surveys may not lower the stress level. Management will just make sure that you are minding your Ps and Qs more often and have more frequent JCAHO readiness memos, meetings, emails etc.

By: Rita

Rita — Thu, 22 Dec 2005 21:21:00 +0000

To Aggravated Doc -
Yes, it will be interesting to see whether the stress levels go up or down based on unannounced surveys. At least we won’t experience the same six-month pre-survey frenzy that is so common now. The day the team shows up however, will probably equal at least one month’s frenzy all rolled into 8 hours.
Whatever you think of the Joint Commission, you’ll no doubt get a chuckle out of the truthfulness of this Brigadoon reference from an April 2004 post by A Chance to Cut is a Chance to Cure:
Are the inspectors so dense that they think the hospital looks and runs like this all the time? What the surveys create is some sort of medical-based Brigadoon where the ideal hospital only appears every three years.

By: Aggravated DocSurg

Aggravated DocSurg — Thu, 22 Dec 2005 20:05:34 +0000

Actually, the incident you described above showed a failure of that institution, on numerous levels, that have nothing to do with JCAHO. Credentialling must always go through a credentials committee, made up of physicians who are interested in ensuring that any potential applicant has the capability of caring for patients in their institution. Approval of said credentials committee should then go through the medical exec. committee, as a further check. Finally, the head of the OR has the responsibility to ensure that a new surgeon on staff has received their credentials via the above process before allowing him/her to schedule cases.
The administrator in the instance you described above should not have been able to override those committees (at least that’s the way things work in every institution I have heard of).
Thanks for your comments — I think you might change your views when unannounced surveys start taking place!