HELP!! JCAHO is coming!

  1. I am about to go through my 1st JCAHO survey. I would like all of you that have been through this to give me some advice!! I am scared, even though everybody says I shouldn't be. Any comments or suggestions will be appreciated!!
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  2. 8 Comments

  3. by   wildtime88
    First, relax

    Just answer the questions they ask you truthfully. If you do not know the answer then look it up or find someone who can.

    I love it when JACHO is coming through staffing is optimal even on the night shift. In fact, there are so many staff you almost trip over them because you are not use to it.

    JACHO reps just go along with it like it is the normal situation and then leave. They know how to play the game and are well rewarded by the luxury treatment they receive.



    As a traveler, I have been trough about 6 JACHO inspections in the last 3 years.
  4. by   mopsi
    You don't state if you are at a hospital or LTC facility. I have been thru one hospital inspection and 4 LTC inspections.In both cases the staffing increase was really amazing. The housekeeping staff super cleaned everything...I never knew those floor could shine like that..Linen was in abundance.Meals were actually attractive and tasty.Supply roons were stocked and organized. In the LTC the usual loud incessant pages were at a minimum. I swear the receptionist was replaced because she never sounded that good before of after. The spotlight tends to be on documentation and record keeping more than things like sterile dressing changes.They look at logs of refrigerator temperatures and logs of accucheck machine calibrations..JACO focuses more on areas administration is responsible for...far more than the routine staff.You need to know where your policy and proceedure books are and how to look things up.They are big on the hazmat/chemical books. Room temps and maintence issues.It's nothing like when the state comes in...at least for nursing...This has been my take on it...I also perscribe to the stay busy and stay out of their way approach....not a good time to be hanging out at the nurses station. I try to be well rested and dress a little sharper.It seems to help in dealing with mgmt and helps my nerves too if I have my act together...Low profile..helpful only if asked...appear composed..Stuff some extra gloves in your pocket..GOOD LUCK
  5. by   prmenrs
    Our Administration grilled and drilled us on what we needed to know--even gave us a booklet w/ all the necessary ??'s and answers. The hospital spent the last year prepping us for it.

    Mopsi's right about the place never looking better, and great staffing. We had extra nurses on our unit updating Policies and Proceedures, making fix-it lists (Hospital even had an official "fix-it" team), got rid of old ratty-looking furniture and got some new stuff. It was kinda fun getting stuff fixed or replaced we'd been asking for since last JACHO 3 years ago.

    In CA, Dept of Health Services comes at the same time, so had their stuff to pay attention to also.

    All the prep paid off--we got 95 from JCAHO, and no "type I's" from DHS. They even complimented us on how well the facility has been maintained even though it's an old county hospital taken over by a University. That rating is the best in the city--another hosp got 96, but they had a type I.

    My contribution was "competencies" for the volunteer "cuddlers" who come in to hold babies for us, and to NOT be scheduled for work when they were supposed to be here!!!

    It's over for now, we can relax for a couple of years till it's time to do it again--and that one should be the LAST before retirement!!
  6. by   RNKitty
    When you see JCAHO coming, be really busy with a pt who is in need of a bed bath or something.
  7. by   OneChattyNurse
    I had my first JCAHO this past summer. I wasn't really worried, as I have been through numerous state surveys in LTC settings. I was suprised I did not see more of the JCAHO staff, their main focus does seem to be documentation. I would gladly take JCAHO over state surveys anyday!!!! That can be a DREADFUL experience!!!!

    Shari
  8. by   NRSKarenRN
    Big on Sentinel events: staff understaning of their part ( My HH agency's QI bulletin board for next two months) and standards; are they being documented as proof of performance.

    Website re above:
    http://www.jcaho.org/ptsafety_frm.html
  9. by   NurseDennie
    I would add this - don't answer anything they don't ASK. Don't volunteer.

    Be sure you know all the things that the hospital has posters up about - like what does PASS stand for in a fire drill, and how does your facility deal with fire drills, storms, etc., etc. Know where the hazardous materials safety books are, and be able to think of some hazardous materials you work with, if asked (blood products, cleaning products, Oxygen.....)

    When I've been through it before, truthfully, the hospital people come and spend a lot of time getting everybody ready, go through the drills and ask the questions the JCAHO people will ask. The actual visit is usually a bit of an anticlimax. I'm sure you'll sail through without any worries.

    Love

    Dennie
  10. by   P_RN
    Don't you love how the clipboard people like to make it seem like a real inspection? Ohhhhhh JCAHO! They give you like 6 months advance notice...SURPRISE!

    My favorite cheat-sheet note from the powers that be (TPTB) was to say, "I'm sorry I don't know the exact wording of that document, policy whatever, but I will show you where it is kept for reference." Like I had an extra minute to find them a book.

    The last inspection our unit had, the guy took the charge nurse to the code cart and quizzed her on every piece of equipment and every med in the drug box. Hmmmmm.

    Mum's the word, and keep out of sight.

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