Inpatient Practice Life In The Hospital

The JCAHO Site Survey

We just went through our Joint Commission site survey and I have a few thoughts after doing this as a medical director. The Joint Commission for the Accreditation of Healthcare Organization (JCAHO or just “Joint Commission”) is the largest of several organizations that review and accredit hospitals in the United States. Hospitals pay the Joint Commission to do a top to bottom review of the hospital every 3 years and they look at everything from medical records, to equipment, to policies, and to the plumbing. The stakes are high: if you lose your accreditation, you can lose your ability to see Medicare and Medicaid patients. I’ve participated in about 2 dozen Joint Commission surveys between Ohio State and Select Specialty Hospitals in various medical director roles. This year’s survey was the first that I have gone through as a medical director for the whole hospital.

Each hospital will have an open “window” of time every 3 years that the Joint Commission can show up. The surveyors will show up unannounced at the hospital administration offices, typically on a Monday at 7:30 AM. The hospital then gives them access to all patient care areas, medical records, policies, etc. and the surveyors inspect… everything.

The number of surveyors can vary in number depending on the size of the hospital and other factors. This year, we had 8 surveyors: a social worker/counselor, a pediatric critical care nurse, a women’s health nurse practitioner, a former hospital chief nursing officer, an OR nurse, an infectious disease physician, a pediatric oncology nurse, and a former fire marshal. The social worker and the fire marshal were only here 1-2 days but the nurses and physician were here daily from Monday through Friday.

The survey consists of informal inspections and relatively formal sessions where one of the surveyors will sit down with a group of hospital leaders to discuss things like medication safety or credentialing. The real detailed part of the survey is when one of the surveyors goes to inspect a specific practice location. They may do this by deciding to go to the respiratory therapy department in the morning and the physical therapy department in the afternoon. They can also do this using a “tracer” method where they randomly pick a patient chart and then retrospectively follow that patient’s hospital course from when they first arrived in the emergency department to the operating room to the ICU to the nursing unit. They will inspect each location and interview staff at each location.

At our hospital, we have an accreditation specialist whose primary job is to ensure that we are always meeting accreditation standards for a variety of organizations that inspect us periodically. Each person who works in a hospital has a role to play during a Joint Commission site survey. As the hospital medical director, I found my role was a bit different than it was when I was a chief of internal medicine, MICU medical director, or PFT lab medical director. Here are some pointers:

  1. Read your bylaws and know what is in them.
  2. Know what is in your medical staff rules and regulations. I printed out a list of the titles and carried it with me.
  3. Know what your various hospital policies are. Again, I printed out a list of the titles to carried it with me.
  4. Have the policies and rules/regulations at hand. Ours are on our internal hospital internet site so I carried an iPad with me so I could pull them up if needed.
  5. Seek out the surveyors and introduce yourself. Accompany them when possible so you can answer questions.
  6. There is a penalty for guessing. You’ve spent your entire life taking multiple choice questions and knowing that if you don’t know the answer, you still have a 20% chance of getting the question right if you guess. With a Joint Commission survey, a wrong guess about something can be lethal. It is better to say that you don’t know and would have to check the files than it is to guess and be wrong.
  7. Get the medical staff involved. Too often, when they know that the JCAHO is in the hospital, the doctors will hide out in their offices or the doctor’s lounge. The surveyors really like to see the physicians engaged in the process so take time to introduce them.
  8. Walk through the hospital. The best way to keep your backyard tidy is to poop-scoop weekly all year round. But if you are hosting the annual office cook-out at your house, you still want to do a quick walk through the grass an hour before the party starts just to be sure. Same goes with a survey. Look for stuff stored in the hallways, unsecured medication drawers, dust on the sprinkler heads, and water stains on the ceiling tiles.
  9. Timing is everything. The surveyors are likely not going to be judging you on your choice of a statin in hyperlipidemia. It is just too subjective and hard to do in a short survey. What they can and will judge you on is whether you adhered to your policies. So, if your policy says you need an H&P on the chart less than 30 days before a surgery, that H&P better be dated < 30 days earlier. If your policy says that the anesthesia assessment needs to be done immediately before surgery, it better be timed before the start of the surgery.  If your policy says that a preliminary op note needs to be in the chart before the patient leaves the OR area, it better be timed before the time the patient is transported to the floor.
  10. It’s your policy, stick to it. Don’t make policies that the doctors can’t adhere to. A policy is what your doctors have to do every time, not what they should aspire to eventually do. If you put in your policy that your doctors need to assess the Mallampati class prior to doing procedural sedation, it has to be done and documented every single time.
  11. Everything expires. This is low-hanging fruit for a site surveyor, every bottle and package in your hospital has an expiration date whether it is a medication, a test strip, or a cleaning agent. Be sure that someone is checking them regularly. After our recent Joint Commission survey, I went through my refrigerator at home… there was salad dressing from 2011 in the back. Good thing they were inspecting the hospital and not my kitchen.

But the good news: we passed our survey. Next week, we have to start preparing for the next one.

September 9, 2016


By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital

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