JCAHO Will Shift to Unannounced Surveys by 2006

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

The Joint Commission plans to introduce a substantially new accreditation process beginning in January of 2004 that has been widely discussed with accredited health care organizations during the past year. The proposal to transition to unannounced surveys, which was approved by the board of commissioners at its March 28-29 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 JCAHO president Dennis S. O'Leary, MD. "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."

The new process will provide "strong incentives for organizations to provide safe, high-quality care at all times," stated Bernard L. Hengesbaugh, chairman of the 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, in Chicago, IL, 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, MD, chief medical officer at Children's Memorial Hospital. "We are eager to 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-hospital systems and alliances have committed to having a number of their hospitals participate in unannounced triennial surveys in 2004 or 2005. They are Ascension Health, Tenet Healthcare, Veterans Health Administration (VHA), and North Shore-Long Island Jewish Health System.

The hospitals of Ascension Health that will be surveyed are St. Joseph Hospital, in Augusta, GA; St. Vincent Clay Hospital, Brazil, IN; St. Agnes Health Care, Inc., Baltimore, MD; Genesys Regional Medical Center, Grand Blanc, MI; Providence Hospital, a member of St. John Health, Southfield, MI; St. Mary's Hospital, Amsterdam, NY; and Seton Health System Inc., Troy, NY.

Up to 20 percent of Tenet hospitals will be surveyed in 2004. Participating VHA facilities are the Desert Pacific Healthcare Network (VISN 22), in California and Nevada; Jerry L. Pettis Memorial VA Medical Center, Loma Linda, CA; VA Greater Los Angeles Healthcare System, Los Angeles, CA; VA Medical Center, Long Beach, CA; VA Medical Center, San Diego, CA; and the VA Southern Nevada Healthcare System in Las Vegas.

Hospitals that will be surveyed in the North Shore-Long Island system, all in New York; are Franklin Hospital Medical Center, Huntington Hospital, Long Island Jewish Medical Center, Southside Hospital, Staten Island University Hospital, and North Shore University hospitals at Forest Hills, Glen Cove, Manhasset, Plainview and Syosset.

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 transitioning 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 5 percent sample of the health care organizations it accredits through the end of 2005. Random unannounced surveys will be discontinued after that time.

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.

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