A decision by the Joint Commission on Accreditation of Healthcare Organizations to make all triennial surveys unannounced as of 2006 was a "logical extension" of its plans for a reformulated accreditation process set to debut next year. But it was not originally part of the design, JCAHO officials said last week.
Removing the advance notice and long lead time associated with on-site evaluation addresses one more complaint from consumer and watchdog groups that the voluntary accreditation process doesn't hold hospitals accountable for the quality of actual care delivery. Accreditation for hospitals doubles as certification for the Medicare program, which the American Hospital Association, among others, wants to preserve.
The addition of unannounced surveys to the impending new accreditation process resulted from months of conversations with hospital representatives, who were concerned about how to reorient their facilities to the JCAHO's stated goal of continuous accreditation readiness, said Russell Massaro, executive vice president of accreditation operations for the Oakbrook Terrace, Ill.-based accrediting agency.
"Right now, everything is built on the survey," Massaro said. The success of the new approach hinges on weaning hospitals off the traditional importance of going all-out in preparations for the visit by a survey team every three years, he said. "This is not just new icing on an old cake. This is a new cake."
The JCAHO's board of commissioners late last month approved the shift to unannounced surveys, which will begin with a pilot program for organizations that have volunteered for the surprise visits during 2004 and 2005. "We had lots of takers, at the corporate level especially," Massaro said (See chart).
"It seems to be obvious that our hospital should be doing this," said Edward Ogata, chief medical officer of 218-bed Children's Memorial Hospital, Chicago, the first hospital in the country to sign up for an unannounced survey. "We should be able to meet any requirement for standards any day of the week, any time of the year."
The revamped accreditation model, un-veiled last fall, relies on computerized information-gathering and a formal self-assessment process to monitor ongoing hospital performance. The objective, Massaro said, is for the triennial survey to be more of a validation process than a singular event for documenting compliance with hundreds of accreditation standards and addressing operational improvement (Oct. 7, 2002, p. 8).
Much of the burden of demonstrating compliance will be addressed by walking providers through a self-assessment at the 18-month mark of the three-year accreditation cycle, in which a healthcare organization will evaluate its own compliance with applicable standards and develop a correction plan to be validated by surveyors during their triennial visit.
That will free up surveyors to focus on a handful of critical patient-care priorities identified before the visit. Under the new approach, surveyors will choose active medical records at random and trace a patient's treatment throughout a hospital stay, evaluating actual performance against standards of good practice.
"Being ready for a thorough survey at any time is a logical extension of the accredited organization's commitment to continuous improvement," said Bernard Hengesbaugh, JCAHO board chairman.
The move to unannounced surveys did not come as a surprise to the American Hospital Association, which appoints seven members of the 28-member JCAHO board, said spokesman Richard Wade. "This was not new; our commissioners supported it. We knew it was coming," he said.
"The pilot is going to be important," Wade said. Hospitals need to be assured that the triennial survey is a validation element of a larger evaluation process and not "the old-time survey done as a surprise," he said.
"If it proves to be workable, it could have a big boost in the public's confidence in accrediting of hospitals," Wade said.
A 1999 report by the HHS' inspector general's office recommended seven changes to tighten up JCAHO oversight. The No. 1 suggestion: "Conduct more unannounced surveys, both regular surveys and surveys made in response to complaints."
Groups representing healthcare consumers and unionized employees said the report did not go far enough. Public Citizen's Health Research Group said at least half the regular surveys should be conducted with no prior notice. "Only through unannounced surveys can the Joint Commission be sure that it is seeing the hospital as it functions from day to day, rather than what it looks like after an extensive `cleanup' and cosmetic improvement program," the group said in written comments on the inspector general's findings.
In another written statement, the Service Employees International Union said all accreditation surveys for the purpose of qualifying hospitals for Medicare should be unannounced.
Massaro said the 1999 report "was not the driver" of the JCAHO decision. The bigger concern among commissioners and hospital executives was that hospitals accustomed to the traditional survey emphasis would reflexively "ramp up" for the visit instead of recognizing the ongoing importance of resolving quality issues, he said.
Ogata said he saw the revised survey process as "a vast improvement" over the documentation-focused whirlwind he inherited when he became chief medical officer at Children's Memorial five years ago. "It just seemed artificial" and "didn't really capture the essence of what goes on in a hospital," said Ogata, who had been a neonatologist and not closely attached to the hospital accreditation process.
"Most hospitals are doing a lot of preparation as if it was an examination," he said. The revamped accreditation "drives an organization to be constantly mindful of what we need to be doing" to meet or exceed care standards.