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Surveying by Surprise

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When surveyors for The Joint Commission showed up unannounced on Jackson Hospital’s doorstep last summer, the hospital staff was unfazed.

“We are ready for The Joint Commission to walk in at any moment,” says Don Henderson, president and chief executive officer of the 344-licensed-bed Montgomery, AL, hospital.

As of last year, the commission began doing just that. The organization implemented a policy of unannounced accreditation surveys as a way of motivating hospitals to meet its performance standards at all times. Unannounced inspections are one of several changes undertaken by The Joint Commission as part of its own performance improvement initiatives, says Linda Murphy-Knoll, the commission’s vice president of operations.

Jackson Hospital was one of 1,415 hospitals that received an unannounced survey in 2006, the first year of the commission’s new protocol. “All things considered, it was a good wake-up call to the hospital field to raise our level of awareness and our readiness,” Henderson says of the surveys. “With the level of preparation that goes on here on a daily basis, there is no question that we are more ready to meet the needs of the community.”

The commission accredits some 5,500 hospitals—more than 85 percent of all U.S. hospitals representing about 95 percent of the country’s hospital beds. When the commission created its new policy, nearly 5,500 hospital CEOs started to twitch when they first learned of the commission’s plan to pop by without warning.

“There was a lot of concern in the field about, ‘How will we know? What if our leaders are not there? What if key staff are not there? It will be terrible. It will be chaos,’” says Joseph L. Cappiello, the commission’s vice president for accreditation field operations. Cappiello credits a training plan for hospitals with easing those fears. “When 2006 came and we went unannounced, it really was pretty much of a nonevent. Most of the feedback that we’ve gotten has been, ‘Why did you wait so long? You should have done it a long time ago.’”

James A. Gomez, quality manager at Florida Hospital DeLand, a 156-staffed-bed hospital near Daytona, has been through six surveys in his career, including an unannounced survey in April 2006. To prepare nursing staff for The Joint Commission’s “tracer methodology,” in which surveyors observe the care provided to individual patients, Gomez sends “mini tracers” to every nursing unit each month.

“We actually have mock surveys that we perform every other week,” he says. “This is part of our life. We have to be ready in case they decide to bebop in.”

At Jackson Hospital, Karen Holland, director of quality and regulatory compliance, uses a dashboard—a document that highlights performance status—to keep staff, management and board members apprised of performance metrics. “We measure ourselves monthly to be sure we’re in compliance with each of The Joint Commission areas,” she says.

Henderson says the dashboard tracks about 30 different performance areas that need to be monitored for the commission, Medicare or private insurers. “Because we initiated that process well before The Joint Commission arrived, we were pretty well up to speed on most of the areas that needed attention,” he says.

If their hospitals are prepared as they should be, CEOs should not worry about being away when surveyors show up, Murphy-Knoll says. “We had several occurrences where the CEO was out of town or the chief nurse was out of town or the quality person was out of town,” she says. “We have done a lot of preparatory work with hospitals about what you need on hand and how to have a backup all the time.”

That’s The Joint Commission’s perspective. Don Henderson’s perspective? Make your best guess as to when the survey is likely to happen—and stay close to the hospital during that time period.

Henderson’s hospital staff figured the survey would occur in the summer of 2006, which was the three-year anniversary of the previous survey. Sure enough, the surveyors rolled up at 7:45 a.m. on July 11.

If they had arrived when he was on vacation, the vacation would have ended abruptly.

“No matter where I would have been I would have come back if I got word of the survey,” he says. “It may have taken me 24 hours to get there, but I would be there. As CEOs we have a sense of personal responsibility about the facilities we operate.”

Lola Butcher is a Springfield, MO-based freelance writer and a frequent contributor to HealthLeaders magazine.