JCAHO Suprise

  1. Just heard that beginning in 2006 all JCAHO accreditation visits will be unannounced. Has any one heard the same and if so do you have any details?
    It is a step in the right direction if it will result in truly suprise visits and stop the waste on the current sham inspections.
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    About OC_An Khe, BSN

    Joined: Nov '00; Posts: 1,133; Likes: 720
    RN pacu CPAN; from US
    Specialty: 40 year(s) of experience in Critical Care,Recovery, ED


  3. by   kitty=^..^=cat
    This press release is posted on the JCAHO website --

    JCAHO to Shift to Unannounced Surveys by 2006
    Media Contact:
    Charlene D. Hill
    Media Relations Manager
    E-mail: chill@jcaho.org

    (Oakbrook Terrace, Ill. - April 2, 2003) The Board of Commissioners of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) today announced its intent to begin conducting all regular accreditation surveys on an unannounced basis beginning in January 2006. Unannounced surveys will be pilot-tested in volunteer organizations during 2004 and 2005.

    Joint Commission plans to introduce a substantially new accreditation process beginning in January 2004 have been widely discussed with accredited health care organizations during the past year. The proposal to transition to unannounced surveys-approved by the Board of Commissioners at its March 28-29, 2003, meeting-was a direct outgrowth of those discussions.

    "The new accreditation process-dubbed Shared Visions - New Pathways-creates the expectation that each accredited organization be in compliance with 100 percent of the Joint Commission's standards 100 percent of the time," said Dennis S. O'Leary, M.D., president, JCAHO. "Organization leaders whom we talked to not only agreed with this expectation but further suggested that the next logical step would be the introduction of unannounced surveys."

    "Shared Visions-New Pathways provide strong incentives for organizations to provide safe, high-quality care at all times; such organizations should be prepared for a JCAHO survey at any time," says Bernard L. Hengesbaugh, Chairman and Public Member, Joint Commission Board of Commissioners. "Being ready for a thorough survey at any time is a logical extension of the accredited organization's commitment to continuous improvement."

    Children's Memorial Hospital, Chicago, is the first hospital in the country to seek a totally unannounced accreditation review by JCAHO. The hospital requested the unannounced full survey, which will take place sometime in 2004, to demonstrate its continuous compliance with JCAHO quality and safety standards.

    "It is quite an honor to be the first health care organization in the nation to experience this new process," said Edward S. Ogata, M.D., chief medical officer, Children's Memorial Hospital. "We are both exhilarated and eager to once again demonstrate the excellent clinical care for which this hospital is known."

    During 2004, the Joint Commission expects to initiate pilot testing of the unannounced triennial survey process in up to 100 hospitals that have volunteered to be among the first participants. Four multi-hospitals systems and alliances-Ascension Health, Tenet Healthcare, Veterans Health Administration and North Shore-Long Island Jewish Health System-have committed to having a number of their hospitals participate in unannounced triennial surveys in 2004 or 2005 (see accompanying list).

    In 2005, JCAHO will continue to conduct voluntary unannounced surveys on a limited basis - opening up the option to all types of accredited organizations, and then transition to a completely unannounced survey program in 2006. During this period, JCAHO will work closely with its various advisory groups, accredited organizations and other stakeholder groups to gain their input and progressively refine the new accreditation process and smooth the transition to unannounced surveys.

    The Joint Commission plans to continue to conduct one-day random, unannounced surveys in an annual five percent sample of the health care organizations it accredits through the end of 2005. After that time, random unannounced surveys will be discontinued.

    Details about the plan to introduce unannounced triennial surveys will be shared with accredited organizations in the coming months through educational programs, newsletters and other outreach activities.

  4. by   Edward,IL
    The bottom line here is that JCAHO is trying to shine up it's tarnished image in the eyes of consumers and nurses. The idea that they work to improve standards of care is still a sham.
    Edward, IL
  5. by   renerian
    Should be unannounced..................farse to tell people your coming.

  6. by   wolfie
    Well since alot of hospitals are dropping JCAHO I would think that would propel other hospitals to drop them. I hope so because I believe that JACHO has done more to harm nursing then help it.
  7. by   NicuGal
    We had a surprise visit by them a few weeks ago...a disgruntled worker called in a false report. We got 3 level one warnings due to that. I don't think that this person realized that if the accusations were found to be true, the hospital would have been shut down within 6 months.
  8. by   ceecel.dee
    I've heard that the surveyors must now prove competency of their own...so all surveyors are playing off the same rule-book page in their inspections. Up to now....as bad as OSHA in regard to subjectivity of individual inspectors.

    It's all good!
  9. by   P_RN
    It is a good thing.
  10. by   night owl
    It's about time!
  11. by   deespoohbear
    Originally posted by Edward,IL
    The bottom line here is that JCAHO is trying to shine up it's tarnished image in the eyes of consumers and nurses. The idea that they work to improve standards of care is still a sham.
    Edward, IL
  12. by   angelbear
    I like that idea. I hope they do it in LTC as well.
  13. by   Nurse Ratched
    Originally posted by angelbear
    I hope they do it in LTC as well.
    Angelbear - I agree COMPLETELY. It's such a joke that facility administrators always know the inspectors are coming so they can spruce up the place and get decent staffing levels for one day every year.
  14. by   Agnus
    Some times I think we confuse state inspections with JAHCO. My guess is the complaint that NICUGAL talks about was filed with the state.
    JAHCO is a voluntary acrediting agency and is not a requirement. JAHCO conducts inspections by invitation of the facility seeking acreditation.
    State inspectors on the other hand do not need and invitation and have the power of state laws behind them. JAHCO does not.

    That is not to say JAHCO acreditation cannot be withdrawn. However, it takes a LOT for that to happen. Unless a facility ops to forgo recertification when it is due.

    JAHCO would not drop a facility for a single reported incident any more than they do when finding these during certification inspections.

    Keep in mind that just because something was reported and did acuality happen does not mean it can be adequately substantiated with inspectors.
    Last edit by Agnus on Apr 6, '03