Print

Print


        I just recently went through my first JCAHO survey.  It was quite an
experience and I was surprised at how different it was from what I'd been
told to expect.  I think my first clue that the process had changed
radically was when I found a document on the JCAHO website detailing the
changes to the IM/Medical Record review interviews (at
http://www.jcaho.org/accred/medrecs/summary.html if you are interested).
I'd been told that our IM team would be interviewed for 45 minutes to an
hour.  Then I saw this document stating that we would have 15 minutes to
discuss all of the Information Management items--material that took up three
large binders for the document review session.  It turned out that was
exactly what we had--15 minutes.  In fact, one of the surveyors was so
concerned about time he kept looking at his watch.  That interview didn't
last one second over 15 minutes.  The library wasn't mentioned once, but
neither were numerous other items covered in the IM standards.

        What was discussed in the interview was planning--they spent the
most time on that, with most of the questions being directly aimed at the
head of our Information Systems department.  The questions weren't even
thrown out to the group--the surveyor turned right to the IS director and
asked him directly.  Our computer system was discussed in depth (or as much
in depth as you can get in about 5 minutes!), then the discussion turned to
patient confidentiality.  It was stressed that workers should only get as
much information as needed to do their jobs.  When the fact that all
employees sign a confidentiality policy when they are hired and that this
policy is signed again every year was brought up, the surveyor asked if
anybody had ever been fired for breaching confidentiality (the answer was
yes, which was good...the surveyor said a policy doesn't work if it isn't
enforced and people don't know there are consequences).  Security was
brought up briefly, as was a backlog in our medical records department
caused by losses in personnel, including our director leaving.  The backlog
had been caught up by an outsourcing firm, but the surveyors saw it and
asked the cause/effect/solution.  That was it, our fifteen minutes were
over.

        Like others have mentioned, I was a bit upset since I'd spent so
much time getting ready for the interview only to have my work ignored.  A
couple of other people in the interview seemed to feel the same way.  We
consoled ourselves with the thought that maybe our departments would get
more attention in the second IM interview scheduled for our second hospital
the following week.  Instead, that interview was cancelled altogether so the
surveyors could spend more time on the closed record review.

        Overall, it was a very strange experience and not at all what I'd
been told to expect.  From what I've been told by other, more experienced,
members of our IM team it seemed as if the surveyors have been told what to
zero in on and that is what they are doing.  One of our managers commented
that he'd never been through a survey with such an obvious agenda--the
surveyors know what they are looking for and won't be distracted by anything
else.  One of our teams put together a presentation for their interview and
found themselves being interupted every other minute with questions
unrelated to their presentation.  Our team had discussed a presentation but
decided to go with the question/answer format instead.  Good idea, since
presentations don't seem to be as accepted as they once were.

        The administrator surveyor did stop by on the building tour, but
stayed only about 30 seconds--I got a phone call right after I introduced
myself and he moved off into the doctor's lounge.  He came back through the
library, asked if I had the Internet (yes), then moved on to another part of
the building.

        I think what really caught some of my coworkers off-guard was a
sense of complacency.  They'd been through a lot of surveys and expected
pretty much the same thing this year and ended up getting some unpleasant
surprises.  So if you're new to the survey process and are sitting in a
preparatory meeting for JCAHO and somebody says something along the lines of
"I've been through this five times and its always the same", which happened
to me, you might want to take their advice and comments with a grain of
salt, do your own research, and get some comments from those who were
surveyed in 2000.

        Melissa Hudak
        Centegra Health System
        McHenry IL