ED Accreditation Update: Surprise! Are you ready for a random survey?
Process allows chosen few’ to fine-tune
Your hospital successfully earned accreditation a year ago. But how ready would you be today if a team from the Joint Commission on Accreditation of Healthcare Organizations walked into your emergency department (ED) as part of a random, unannounced survey?
Though brief and unannounced, the random surveys can carry a big punch: The survey results could lead to new Type I recommendations and could cause a change in your organization’s accreditation status.
"Everybody thinks about it, because from your ninth to your 30th month [following a triennial survey], you’re at risk for a random survey," says Paula Swain, RN, MSN, CPHQ, director of clinical and regulatory review for Presbyterian Health Care in Charlotte, NC. Swain has consulted with organizations that have been through random surveys, and none have received new Type I recommendations as a result.
Once you have your survey, you don’t go on vacation, Swain emphasizes. "You have to clear your Type I [recommendations] and your supplemental [recommendations that must be addressed by the organization], and then you have to continuously work to keep your standards in place on a day-to-day basis," she says.
The Joint Commission has conducted one-day, random surveys of accredited organizations since 1993 as a means of determining whether an organization observes compliance with standards on a routine, day-to-day basis. Each year, 5% of accredited organizations are selected from across all categories. There is no advance notice.
The fixed topics that surveyors look at during these random surveys change every year. Because the ED often is the first area of a hospital that a patient comes to, and where the most critical care may be administered, certain aspects of the fixed topics may be especially pertinent to the ED. For this year, the fixed topics for hospitals are surveillance, prevention, and control of infection; initial patient assessment; leadership’s role in improving performance; medication use; and human resource planning.
"The infection control standards and medication use standards are probably the biggest two areas for the ED," according to Robert Katzfey, associate director and surveyor of management and development for the Joint Commission.
Here are some ways each of the five fixed topics may apply to the ED of a hospital selected for a random survey:
• Infection control. Surveyors will want to look at equipment used and reused in the course of a busy day, how that equipment is cleaned, and what infection control procedures are followed, Katzfey says. Also, what potentially harmful supplies are used that could pass infection between patients? What are the hospital’s procedures for hand washing and use of gloves and gowns, and do ED staff members comply with those procedures?
"We’ll want to look at the hospital’s infection control surveillance activity and how that activity is utilized in the ED," Katzfey says.
• Patient assessment. Surveyors will look at how initial assessments are done on patients presenting to the ED; who staffs triage; who manages triage; what information is obtained and how quickly it is obtained; and how quickly the appropriate treatment course is determined.
"Certainly, if a patient is going anywhere else [in the hospital] from the emergency department, a thorough evaluation of the patient’s needs at the time of presentation is critical," Katzfey notes.
• Medication use. Katzfey says that important areas for the ED are: access to medications during hours when the hospital pharmacy is not open; the competency of individuals who obtain and administer medications; steps taken to ensure the proper identification of patients before medication is administered; and security of medications that are kept in the ED.
• Leadership’s role in improving performance. This area of assessment looks at how hospital leadership sets priorities and plans for action in areas identified as in need of improvement.
• Human resource planning. Surveyors will want to examine the effectiveness of staffing, which, due to the fluctuations in patient volume in EDs, can be challenging.
"We’re not only looking at whether the three RNs and two aides who were scheduled to work the 11-to-7 shift on Tuesday were actually there, but whether that’s the appropriate level of staffing for that shift, and what criteria are used to determine staffing levels," Katzfey says.
Another aspect of that topic involves use of staff from outside agencies. According to Katzfey, hospitals need to be sure that ED staff members from outside agencies are just as competent as regular hospital staff.
Depending upon an ED’s use of outside agencies for staffing —how many contract agents are used and how often they work — the performance of those employees must be evaluated, Swain says. "You have to be sure that outside people know what they’re doing and that they do it as well as your regular staff," according to Swain. "You can either get an evaluation from the agency, or the ED managers can do it themselves; if [staff from agencies] are working that much, though, the [ED] managers should do it themselves."
According to Jodi L. Eisenberg, CPHQ, CMSC, coordinator of accreditation and licensure, quality strategies, at Northwestern Memorial Hospital in Chicago, the random, unannounced survey is an inevitable fact of health care today.
"Health care organizations are randomly visited not only by the Joint Commission, but by . . . a variety of other regulatory agencies," Eisenberg says. "They are unexpected company — not on the calendar for the day. "
However, Eisenberg says she may be in the minority who feel that random, unannounced surveys have merit. "They force organizations to realize that compliance with basic standards is an everyday responsibility, and not just a triennial activity," she says.
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The Joint Commission accredits more than 17,000 health care organizations in the United States and internationally. These organizations include hospitals, assisted living facilities, critical access hospitals, clinical laboratories, home care organizations, long-term care facilities, office-based surgery practices, behavioral health care facilities, and health care networks. |
Sources and Resources
For more information on random, unannounced surveys, contact:
• Robert Katzfey, Associate Director, Surveyor of Management and Development, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5021. Fax: (630) 792-5005. E-mail: [email protected].
• Paula Swain, RN, MSN, CPHQ, Director of Clinical and Regulatory Review, Presbyterian Health Care, 200 Hawthorne Lane, Charlotte, NC 28204. Telephone: (704) 384-2273. E-mail: [email protected].
• Jodi L. Eisenberg, CPHQ, CMSC, Coordinator, Accreditation and Licensure, Quality Strategies, Northwestern Memorial Hospital, 676 St. Claire, Suite 700, Room 7-005, Chicago, IL 60611. Telephone: (312) 926-5705. E-mail: [email protected].
Your hospital successfully earned accreditation a year ago. But how ready would you be today if a team from the Joint Commission on Accreditation of Healthcare Organizations walked into your emergency department (ED) as part of a random, unannounced survey?
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