A Closer Look at Unannounced Surveys
William T. Foley, President and CEO, Provena Health:
In my years in health care—I've been in health care leadership over 30 years now—and I think of the old days when preparing for a Joint Commission survey was like cramming for an exam in college. In the months and weeks before the survey, everybody is scrambling around the hospital to get ready. You know, I think the process now with the unannounced survey really puts you in a situation where you're continuously ready, you don't have lapses, you really are on top of things, again, especially with the focus on quality and patient safety. I don't know why any organization would not want to do it.
Margaret C. Gleason, R.N., M.S.N., President and CEO, Provena Home Care:
In the beginning, I was upset about it, I'll be honest with you, but I really think it's the right thing for the Joint Commission, because in my previous history we all geared up for when the survey was, and we were all perfect for a week, and then we didn't maintain it most of the time, so I think it's better for the Joint Commission to be unannounced, because they can come in and see that you are doing what you say you should be doing.
Joe Cappiello, Vice President, Accreditation Field Operations, Joint Commission:
The first thing that the unannounced process does as the capstone to Shared Visions-New Pathways, it really ensures that there is no bias in the survey results, that we see what we see when we're on-site, we get a unbiased view of the way that that facility works day in and day out, the preparation of its staff and all of the activities that go on within that facility to provide high quality, safe patient care.
Testing the process
Linda Murphy-Knoll, M.N., Vice President, Accreditation Service Operations, Joint Commission:
When we determined that we did need to go unannounced, we also determined at the same time that we really needed to do some extensive pilot-testing. We also knew that we wanted to pilot-test all types of organizations, from home care to long-term care, laboratories, ambulatory, and hospitals. Every type of organization that we survey, we knew we needed to go into those organizations unannounced and just test the process, but we also knew that we needed to do that in just the two years before the actual unannounced process started, and so determined that we would ask for volunteers.
Now, when these folks volunteered, these surveys were real. It wasn't like a pilot test where we went in and it didn't count. They actually knew they were volunteering for a real survey, felt they were in continuous standards compliance, and were ready for this type of shift, and volunteered in 2004 and 2005. In those two years, we had about 130 volunteers, about 40 or so in 2004, and about 80 to 85 in 2005.
Margaret C. Gleason, R.N., M.S.N., President and CEO, Provena Home Care:
The procedures that were different were not pouring over the policy and procedure books, not looking at the contracts. Their methodology was a little different that way. Actually, tracer methodology for home care was the same. We've always done tracer in home care. But looking at the contracts and the back room things were a little bit different. She didn't go into those unless she found an issue with a chart, and then she would say, "Show me your policy in reference to this," or, "Show me the contract that you have with this company." So that was a little different, because usually in the beginning days you always hit the policy and procedure book hard.
The morning of your survey
Joe Cappiello, Vice President, Accreditation Field Operations, Joint Commission:
At around 7 a.m. in the morning, of the day that the team is to arrive, posted onto the secure extranet site, which is the secure link between the facility and the Joint Commission, we will post information that says today is day one of the survey, and we will also post the bios and the names of the surveyors who are going to be there, and there will also be a letter from the executive vice president of accreditation operations, Russell Massaro, that will outline the team and what the team is going to be there for and the length of time that they are going to be on-site.
The surveyors present themselves at the front door, at security, wherever the point of entry into the facility is. They will announce that they're from the Joint Commission, and they will not ask to be shown throughout the facility, they will wait there until leadership has validated on the extranet that they are from the Joint Commission, who they are, will see their biographies, by March they will begin to see their pictures, and so there is a validation that they are who they say they are.
Linda Murphy-Knoll, M.N., Vice President, Accreditation Service Operations, Joint Commission:
Actually, the on-site process will change very little for organizations. In the testing, we found that really unannounced and the tracer methodology and the way that the new Shared Visions survey process is set up is really very compatible. The only thing that we really need to change was the opening hour of the day. Once the surveyor has come on-site, they'll give the organization time to get a room together, get their staff together, make sure that everyone is organized. And in that first hour, the surveyors will do their own planning session, and then start with the leadership conference, but that's really the only change to on-site.
Margaret Gavigan, Senior Vice President and Chief Clinical Officer, Provena Health:
Initially, when the Joint Commission surveyors show up, the first half-hour was nerve-racking during our surveys because it's the day, we didn't know they were coming, and so it's that flurry of activity. But after 30 minutes, after that 30 minutes was over, and we had a paging tree, we had an algorithm for how we would get the right people there to start the process, it really went beautifully. So when we interviewed our staff afterwards, they said it was really just that first 30 minutes that was nerve-racking. After that, the process itself was such a positive experience, and the direct-line staff were such great representatives of our health care system and our hospitals that it flowed really, really well. And there was a real collaborative relationship between the surveyors and the hospital staff and leaders there, and we really enjoyed that collaborative relationship and the education that they provided.
Survey dates
Linda Murphy-Knoll, M.N., Vice President, Accreditation Service Operations, Joint Commission:
In 2006, 2007 and 2008, an organization can expect their unannounced survey to occur anytime from January 1 to December 31, in the year they're due. The only exception to that is labs. We will be surveying labs up to six months before their survey is actually due, not to exceed the 24th month.
The organizations that are surveyed in 2006, 2007 and 2008 could be eligible for another survey within 18 months of their first unannounced, or they could be pushed out to 39 months, and we'll be utilizing specific criteria to make those decisions. But what that really means is an organization that is surveyed in January of 2006, for instance, based on data that we have and criteria that we set, may have their next survey as early as July of 2007.
Blackout dates
Linda Murphy-Knoll, M.N., Vice President, Accreditation Service Operations, Joint Commission:
We do give organizations ten blackout dates. Those are ten days they can choose in any calendar year that we won't come on site, to the best of our ability. We'll do everything we can not to come in those ten days. We want organizations to know, though, not to choose, for the most part, federal holidays, because we don't survey on those days. We also don't survey on Christmas, New Year's, Thanksgiving weekend, so don't choose those type of dates, but do choose any time in between that you feel maybe your whole management team is going to be off-site for a retreat. That might be a good idea.
Exceptions to unannounced surveys
Linda Murphy-Knoll, M.N., Vice President, Accreditation Service Operations, Joint Commission:
As we did our testing in 2003 and 2004, we did find that there were very legitimate exceptions to unannounced surveys. Some of those include the Department of Defense, the Bureau of Prisons, Immigration facilities and office-based surgery practices, where there's really maybe one physician and a nurse, and they do surgery maybe two to three times a week, and we really need to be there when surgery is occurring to survey that organization.
Another very legitimate issue was foster care, and then very, very small programs in general, and those are listed on our website, www.jointcommission.org. Also, initial surveys will be announced. And then finally, we do do disease-specific care, and within 45 days of the date when the organization is due for survey again is when we'll be coming out. All the other exceptions are five days.
Exceptions:
- Department of Defense
- Bureau of Prisons
- Immigration facilities
- Office-based surgery practices
- Foster care
- Very small organizations
- Initial surveys
- Disease-Specific Care
Joe Cappiello, Vice President, Accreditation Field Operations, Joint Commission:
The unannounced process is just the final end product of the evolution of Shared Visions-New Pathways, and it makes so much sense. If our thought was to embed the standards as part of the management plan that management uses to conduct its business and to ensure high quality, safe patient care day in and day out, then moving to the unannounced makes absolute sense.
Margaret Gavigan, Senior Vice President and Chief Clinical Officer, Provena Health:
This is a great strategy to support and ensure that culture of excellence within a health care organization. Secondly, I think you need to really rely on your staff and know that your direct caregivers are going to represent you very well, so it's not as nerve-racking as they really think and that the direct caregivers will really do a great job of representing their organizations. With communication and education of the new process, it will help them to flourish and tell the story of how they take great care of their patients.
For more information about unannounced surveys, visit www.jointcommission.org and your extranet site, or call your account representative.