Joint Commission surprise visits are on tap for 2000

ICPs need to shift to continuous readiness’

Infection control programs could be inspected without warning beginning next year under a new random unannounced survey policy recently adopted by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

Effective Jan. 1, 2000, facilities will receive no advance notice for random unannounced surveys. The window of time during which random unannounced surveys may be conducted will be nine months to 30 months following the triennial full survey. The scope and focus of review during an unannounced survey will vary, but generally will be based on recommendations made during the organization’s previous triennial survey, known sentinel events, and other relevant information regarding the organization’s performance, the Joint Commission reports.

"They look at everything when they tour," says Charlene Hill, Joint Commission spokes woman. "It is entirely possible that noncompliance with infection control standards — as with any standard — could be identified. So, overall, if Joint Commission surveyors see something during the tour that is not in compliance with the standards, they will make the organization aware of it."

In addition to the unannounced survey program, the Joint Commission also is considering developing a presurvey information packet that will provide inspectors with specific information about the health care organization’s performance issues. In addition, the association is pilot-testing the idea of extending on-site surveys to night and weekend periods. Currently, Joint Commission surveys, including most unannounced surveys, are conducted during regular daytime hours.

HCFA turns up the heat

The unannounced survey policy applies to all accredited organizations except laboratories. Previously, the commission conducted unannounced surveys at randomly selected accredited organizations at the midpoint of their accreditation cycles, provided 24 hours advance notice of those surveys, and communicated the standards to be reviewed prior to the survey. However, the Joint Commission has been under increasing pressure from the federal Health Care Financing Administration (HCFA), which oversees the Medicare program, to toughen the accreditation process.

"They are independent, but they receive a lot of funds to perform surveys," says HCFA spokes woman Michelle Robinson. "As you know, we are the largest insurer in the country. We want the Joint Commission to be less collegial and essentially more proactive in dealing with hospitals."

By the same token, HCFA has been under pressure itself after a report by the U.S. Office of the Inspector General concluded that "HCFA does little to hold the Joint Commis sion or the state [accrediting] agencies accountable, obtaining limited information about their hospital oversight activities and providing little feedback about their overall performance. In dealing with the Joint Com mis sion, HCFA is more deferential than directive." As a result of that report, HCFA administrator Nancy-Ann DeParle said the agency would hold the Joint Commission "more fully accountable" to ensure quality of care for Medicare patients. "[HCFA] will work with them to conduct more unannounced surveys and perform more rigorous assessments of each hospital’s internal quality assurance process," DeParle noted.

Triennial chaos may be avoided

Regardless, many infection control professionals are already going to the idea of "continuous readiness," in part to avoid the chaos prior to the traditional triennial visit, notes Ona Baker, RN, MSHA, CIC, infection control coordinator at the Department of Veterans Affairs Medical Center in Amarillo, TX.

"I think the more well-prepared hospitals are pretty much continually ready anyway," she says. "And for several years, there has been this possibility of a mid-cycle unannounced visit at 18 months." In addition, ICPs already are accustomed to the threat of unannounced surveys by compliance agencies such as the Occupational Safety and Health Administration, she adds. Still, many ICPs may typically wait until scheduled Joint Commission surveys approach to pull data together and prepare examples of compliance for inspectors. The surprise visits may call for more routine readiness and documentation of infection control efforts like ongoing surveillance, she says.

"They might also want to see how you’re interfacing with the health department and you may be motivated to have a filing system or something that would allow you to pull up some recently reported examples of how you reported your communicable diseases," Baker says.

Compliance with education requirements is a little less clear, especially at hospitals that use an annual inservice approach to address infection control issues, she notes. In addition to inservice records, it may be important to document infection control education components of other policies and ongoing programs, such as routine prevention measures against bloodborne patho gens, she adds.

(Editor’s note: ICPs wishing to provide feedback on the accreditation process can visit the accreditation improvement section of the Joint Commission Web site at www.jcaho.org. The U.S. Office of the Inspector General’s report is available on the Web at www.os. dhhs.gov/oig.)