American Journal of Nursing 2000 April Volume 100, Issue 4

Does JCAHO See the Truth?

How nurses can alert JCAHO surveyors to staffing problems.

A.
While the survey process, which happens every three years, is generally dreaded, few facilities have suffered significant consequences from an unfavorable review. In fact, recent findings from a Department of Health and Human Services Office of the Inspector General (OIG) investigation noted the collegiality of JCAHO. The OIG report, The External Review of Hospital Quality: A Call for Greater Accountability, investigated the quality of the accreditation processes of JCAHO and state agencies. The report noted that because of time restrictions and a rigid structure, the survey process lacks the spontaneity and scope needed to further assure patient safety and overall quality of care.

Since the release of the report, JCAHO has been revamping its survey process, incorporating many recommendations supported by the American Nurses Association. The following changes in the survey process could allow your input on your facility’s staffing issues to be considered in future surveys.

• “Unannounced” surveys will be truly unannounced. Surveyors will be onsite during evening, night, and weekend shifts. (This is already happening in the first quarter of 2000 as part of a pilot test.)

• Inspectors will have up to six hours to pursue issues specific to the particular organization.

• Surveyors will make longer visits to patient care units.

• They will receive more detailed information about the facility before the survey.

In addition, surveyors will meet with nursing and other staff, patients, and families. You can meet the surveyor during the survey or submit concerns to JCAHO at any time. When reporting your concerns, include a concrete summary of events, dates, and names of patients and others involved, as well as actions taken during and after an event or incident. Simultaneously, you can report concerns to the state agency responsible for certifying hospitals. All hospitals receiving Medicare or Medicaid reimbursement, including those that are JCAHO-accredited, are subject to state requirements and inspections.

If you’re concerned about your facility learning of your complaint, you can submit it to JCAHO anonymously. Consider using an alias, but provide secure contact information because inspectors may need to ask additional questions. Check with your state agency regarding its policies on anonymity and whether your state has whistleblower laws to protect employees from employer retribution for reporting unsafe practices.

Also, if you work in a private hospital, the National Labor Relations Act protects you when working with other employees to address unsafe or illegal activities. If you belong to a collective bargaining unit, your contract should include additional protections to prevent unfair employer retaliation. Work with your bargaining unit and state nurses association (SNA) to identify contract options, or to put together a comprehensive plan for reporting concerns to JCAHO or the state agency.

Call your SNA if you have more specific questions about when and how to report unsafe staffing and quality of care concerns in your facility. To learn when your facility will be surveyed (if it’s scheduled for 2000) or to report specific concerns, go to the JCAHO Web site at www.JCAHO.org, or call (630) 792-5800. For state agency contact information, go to www.hcfa.gov/medicaid/scontact/ htm, or call (410) 786-3000. Your state agency can provide copies of the regulations for hospital licensure in your state.

Resource
The ANA Principles for Nurse Staffing: www.nursingworld.org
(800) 274-4ANA (ask for PNS-1)