February 25, 2005

JCAHO survey preparations begin again

While it has only been a year and six months since the last survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the MGH has already begun preparations for the next review, which is expected to take place some time in 2006.

JCAHO is a nonprofit organization that evaluates and accredits more than 19,000 health care organizations in the United States. The goal of JCAHO is to help improve the quality of medical care by accrediting health care organizations that are deemed to meet specific standards after completion of a thorough inspection.

The early preparations for the survey are to help plan for the major revisions JCAHO has made to the survey process. In 2004, JCAHO launched its new accreditation process called "Shared Visions — New Pathways," which is meant to focus on continuous improvements in an organization with more of an emphasis on providing safe, high-quality care, treatment and services.

One of the major changes to this process is that the survey now will be unannounced, meaning that the MGH will have a general idea of what month the survey will be conducted but will not know the exact days. JCAHO also will use more in-depth information about the hospital to help focus the survey and will use a new process called tracer methodology to analyze the hospital's systems through "tracing" a patient's experience. With this method, a surveyor follows identified patients throughout their care experience, speaking with staff members who care for those patients along the way.

In addition, some JCAHO standards have been reformatted and clarified to focus more on patient safety and quality of care. JCAHO also now requires a Periodic Performance Review (PPR), a compliance assessment that a health organization conducts itself at the midpoint of its accreditation cycle.

The hospitalwide JCAHO steering committee — under the leadership of Maryanne Spicer, director of MGH Corporate Compliance — reconvened in the fall of 2004 to reinvigorate the MGH's planning for the survey. The committee currently is conducting a PPR and will be submitting the results to JCAHO in March.

"The Joint Commission's changes to its accreditation system are moving from a process focused on preparing for a survey and trying to achieve a high score to one that emphasizes continuous operational and system improvements," says Spicer. "While I'm confident that the MGH is always ready to provide the highest quality care at all times for our patients, the challenge with this new survey process is to always be prepared to demonstrate our state of readiness in the case of a surprise inspection."

The JCAHO committee also will reintroduce the hospitalwide FYI campaign, which is a series of informative posters, fliers and articles in hospital publications that convey important information about hospital activities, programs and policies that are integral to the survey. The JCAHO committee is introducing the first FYI poster, which focuses on stroke awareness (above) and is co-sponsored by the Acute Stroke Quality TaskForce.

For more information about the JCAHO survey, contact Spicer at (617) 726-5109.