Hello. I'm from the Joint Commission, and I'm here for your random unannounced survey."
Those words, enough to shake administrators to their boots, will be all the warning that hospitals and other healthcare organizations will get after Jan. 1 about being selected for a midterm checkup.
The new no-notice policy is part of a wholesale revision of the so-called random unannounced survey that the Joint Commission on Accreditation of Healthcare Organizations approved July 30-31. The new tack is to buttress the credibility of the survey and to respond to complaints from the agency's critics, including HHS' inspector general's office, which recently issued a report criticizing the survey process (July 26, p. 2). It should also keep hospitals alert during the three years between their full accreditation surveys.
The JCAHO's various critics grudgingly welcomed the changes but said much more needs to be done.
The American Hospital Association, however, is furious at the policy shift. "We're upset about the outcome and very disappointed in the process (of) how they got to it," said Richard Wade, senior adviser for communications at the AHA. "They want to look more like regulators than quality improvers."
Don Nielsen, M.D., the AHA's senior vice president for quality leadership, said that a January contretemps between the hospital industry and the JCAHO over core performance measures (Jan. 18, p. 14) led him to believe the JCAHO would begin to collaborate on changes. After deliberations with state hospital associations, the JCAHO and the AHA had set up a strategic advisory group to handle this new era of collaboration.
"That group was not convened to have this particular policy discussed," Nielsen said. JCAHO staff had told state hospital associations that any major policy changes would be discussed and pilot-tested, he said. No testing is scheduled for changes in the unannounced survey.
The AHA's seven representatives on the 28-member board of commissioners "most certainly did reflect the concerns we expressed," Nielsen said, adding that the AHA does not instruct its commissioners how to vote. The board vote was not unanimous, but the JCAHO does not record how many members, or who, voted for or against a measure.
The policy change exceeds the recommendation of the JCAHO's Oversight Task Force for Accreditation Process Improvement. That body proposed going to a four-hour notice or a 16-hour notice.
"Whether it was 24 hours, four hours or 16 hours, all it amounted to was a courtesy call to the institution, so somebody could be on-site to be responsive to the surveyors," Wade said. Nielsen scoffed at the notion that hospitals use the notice to haul in extra staff and tidy up. "There is no systematic data that shows that hospitals are gaming the system," he said.
Dick Tompkins, M.D., vice chairman of the JCAHO's oversight task force and an American Medical Association-appointed commissioner, said that "after pretty straightforward discussion (and) no acrimony" the board decided any warning would compromise the public's notion of an unannounced survey.
The allegation that organizations were gaming the survey was the reason the random unannounced program was introduced in July 1993, said Dennis O'Leary, M.D., the JCAHO's president and chief executive officer. The advanced warning was a concession to hospitals.
Roughly 85 hospitals per year have undergone the random surveys.
The JCAHO has been criticized because the surveys are neither random nor unannounced. Hospitals know roughly when they may be surveyed and that they'll be forewarned.
The board has been discussing the survey policy for more than a year, O'Leary said. The recent inspector general's report argued for eliminating the warning for the midterm survey as one of its seven specific policy recommendations.
The JCAHO's response couldn't be perceived as lame, O'Leary said. "It would color people's perceptions of whatever else we do, including the inspector general and the Health Care Financing Administration. They want a little more hardball credibility."