Brace for unannounced JCAHO surveys

January 23, 2006

Hospitals and health systems accredited by the Joint Commission on Accreditation of Healthcare Organizations are getting ready for the first truly unannounced, no-appointment-necessary, on-site surveys. Under the new policy, JCAHO surveyors can show up anytime between Jan. 1, 2006, and Dec. 31, 2006. The only warning facilities will get is a 7:00 a.m. e-mail notification on the morning of the survey.

Small home care organizations that are not part of large healthcare systems, office-based surgery practices with fewer than 1,500 annual visits, and Department of Defense and Bureau of Prisons facilities are among the facilities that will be exempt from the new policy.

Under the old survey policy, healthcare organizations were informed of their due date for accreditation renewal and that JCAHO surveyors would visit no sooner than 45 days before and no later than 45 days after the due date.

What do health-system pharmacists think of the new policy? Vivian Johnson, Pharm.D., director of pharmacy at Parkland Health and Hospital System in Dallas, said she has no problem with the unannounced survey process. "It's basically best practice for us," she said. "We are always working at trying to be continually ready; it's part of patient safety."

After 2009, surveys will occur between 18 and 39 months after the previous full survey. This means, for example, if a facility is due to have a survey in January 2009, it could have its survey anytime from July of 2007 to April of 2010.

In other JCAHO news, Darryl Rich, Pharm.D., a surveyor for JCAHO, told Drug Topics that while there will be no changes in the medication management standards in 2006, the commission will keep a close eye on problem areas. He noted that unapproved abbreviations continue to trip people up on surveys. "More than 50% of organizations are having problems with that," he said. Another big issue that JCAHO surveyors have observed is that healthcare practitioners don't realize that intravenous contrast orders require a pharmacist's review.

Other top medication-related noncompliant standards include: lack of standardized forms, lack of communication of patient information from department to department, inappropriate storage conditions, and sound-alike, look-alike drugs.

Rich said that healthcare facilities also need to keep on top of JCAHO's National Patient Safety Goals. "We have a couple of new ones this year-medication reconciliation is starting up. There have been a lot of questions and a lot of problems with regard to medication reconciliation, and we are going to start surveying in January 2006. And from what I can see, people are not prepared."

Hospitals are expected by January 2006 to document all medications that are taken by patients and ensure that a complete list of those mediations is communicated to the next provider of service, including transfers to other settings or levels of care within and outside the organization.

On the issue of USP 797 compounding guidelines-a hot topic at the ASHP Midyear Clinical Meeting-Rich said that there is a misperception regarding JCAHO's intentions. "We never said that we were going to survey 797, and we don't," he said. "What we do require is that organizations do their own evaluation and come up with an action plan for compliance."

Rich added that JCAHO does not survey anyone else's standards. "When there is overlap, we will survey our standards. But all we are looking for is that they've done that analysis. If they have come to the conclusion that there are certain aspects of 797 that they choose not to comply with, we are not going to penalize them."