Perhaps what has frustrated RNs most about accreditation visits, however, involves staffing practices. The ANA and nurses have long contended that hospitals tend to boost staffing levels on days JCAHO surveyors are present, which gives a false picture of RNs' working conditions and, in turn, patient care. The ANA, for example, received calls from some Washington, DC, nurses who complained that extra staff were sent home immediately after surveyors left their hospital.  

"We've all seen what goes on with JCAHO visits the feverish period of preparation and the celebration afterward" says Michael Evans, PhD, RN, CNAA, FACHE, the ANA’s representative to a JCAHO Professional and Tech­nical Advisory Committee that focuses on hospital accreditation processes and standards. “And then things go back to the way they were before.

“This rollercoaster of events makes staff nurses, and even managers and administrators, cynical about the survey process,” he adds.

However, the JCAHO survey process is changing, and the ANA and many nurses welcome these efforts aimed at ensuring that standards of care are followed 365 days of the year. JCAHO standards focus on a wide range of patient care-related activities and policies, from patient rights to infection control.  

The new survey process is called “Shared Visions–New Path­ways” (Go to www.jcaho.org for more information). Health care facilities are expected to implement certain components of the accreditation process this year, while other components will be phased in later, according to JCAHO.

One of the changes that the ANA strongly lobbied for is the implementation of unannounced site visits, according to Rita Munley Gallagher, PhD, RN,C, senior policy fellow in the ANA’s nursing practice and policy department. Previously, organization administrators knew many months in advance when accreditation visits would take place.

“With this JCAHO change, hospitals will need to be ready 24 hours a day, seven days a week,” Gallagher says.

South Carolina Nurses Association member Ingrid Pearson, MS, RN, CPNP, agrees.

“We should not be ‘getting ready for the guests,’” says Pearson, former ANA representative to JCAHO’s ambulatory care advisory committee. “We should be meeting set standards of care everyday.”

Adds Evans, “If all the things that surveyors look for when they come into a hospital are so im­portant, such as maintaining the temperature of refrigerators where pharmaceuticals are kept, they should be done all the time.”

The JCAHO Web site points out that reasons for the shift to unannounced surveys range from enhancing the credibility of the survey process by having surveyors observe a health care facility’s operation under normal circumstances to promoting safe, high quality care at all times. Currently, JCAHO is testing unannounced surveys of volunteer organizations over the next two years, with a goal of implementing this process throughout the health care industry by 2006. If they’re not participating in the pilot program, health care facilities now have at least four weeks notice before a scheduled site visit.

In addition to unannounced visits, JCAHO is implementing other changes designed to promote continuous quality assurance among its accredited facilities.

“JCAHO wanted to help health care facilities be more efficient, safer, and provide higher quality care,” says Evans, a Texas Nurses Association member. “And it really listened to nurse committee members to help them find ways to ensure institutional readiness and compliance.”

JCAHO is now requiring that health care organizations seeking accreditation conduct a midcycle self-assessment using applicable JCAHO standards. (JCAHO accreditation lasts for three years.) They then must develop a plan to solve deficiencies, as well as prove they resolved those deficiencies.

And when on-site, surveyors will use the “tracer methodology” system that gauges how care is being provided to patients selected at random.  

Angie King, BSN, CPHQ, quality management director at Tift Regional Medical Center in south-central Georgia, saw first-hand the positive effects of these new changes. At King’s urging, Tift administrators agreed to test the new accreditation process last year.

“We saw this as an opportunity to have some say-so in survey changes and get a heads-up on how JCAHO planned to change the accreditation process,” King says.

In explaining the tracer methodology, King says surveyors select current patients and look back on how their care has been provided at every step during their hospital stay. For example, if surveyors opt to follow a pediatric patient, they’d assess the care given from staff in the ED to the critical care unit to the pediatrics unit.

King likes this approach because it breaks down the “silo effect” that often occurs among hospital departments.

“I think it’s a big change for nursing in particular, because nurses can see how the care they gave in the ED, for example, has affected the patient throughout the course of his stay,” she says. “It makes nurses realize that we are all part of the same journey in providing patient care.”

The new process also has alleviated some of the anxiety surrounding JCAHO visits, because, in the past, staff often worried that the organization’s accreditation hinged on what they did or said during the course of the on-site evaluation.

During the pilot on-site survey, staff were more relaxed because they had worked to create a state of continuous survey readiness, according to King.

For example, while conducting the new periodic performance appraisals, King worked with staff to ensure they knew what JCAHO standards were, ways to comply with those standards, and how they would ultimately be evaluated.

Gallagher adds that the periodic self-surveys also benefit surveyors.

“Surveyors used to go into the process cold,” Gallagher says. “They didn’t have the information related to problematic areas. Now they can focus more closely on areas of potential concern.”  

Another major change in the accreditation process involves the development of better avenues for staff input.

“Historically, staff were having problems with their ability to provide potentially sensitive information to surveyors about patient care or procedures,” Gallagher says. Because surveyors were located on-site, staff members who wanted to share their concerns could be observed talking with them.

Now, staff can provide their comments to JCAHO online or call in their concerns without fear of retribution, she notes.

King and other nurses believe that JCAHO is on the right track in terms of improving the accreditation process. They also believe that both organization staff and surveyors will need time to become accustomed to the new system.

“Anytime there is change, there is some cause for fear or trepidation,” King says. “I believe there is going to be a huge learning curve, particularly among surveyors, who will need to get accustomed to the new process quickly, particularly the way they now will evaluate facilities’ compliance with the standards.”

Pearson adds that an effective way to deal with staffs’ understanding of JCAHO changes is to talk about the standards, what they mean, and what surveyors typically look for in relation to compliance.

“The standards represent good practice,” Pearson says. “They are not meant to be outlandish.”

Further, she says, the standards provide people with the security of knowing what is expected of them; they ensure that facilities conform to certain practices, as opposed to allowing facilities to develop their own ideas of what high-quality care means.

Susan Trossman is the senior reporter for the American Nurse, published by the ANA.

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