February 2003

Market-based Organizations Achieve High Scores in JCAHO Surveys


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"They told us not only what to expect during the survey, but how to respond. We wouldn’t have received the score we did without their help." Jeffrey Drop, President and Chief Executive Officer, St. Anthony Hospital

The 15 market-based organizations surveyed by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) during 2002 achieved scores ranging from 91 to 97. "Every organization that was surveyed did very well," said Harold Ray, MD, chief medical officer for Catholic Health Initiatives. "Two of them – St. Catherine Hospital in Garden City, Kan., and Franciscan Health System in Tacoma, Wash. – received no Type I recommendations." Nancy Lima, director of clinical performance improvement for Catholic Health Initiatives, helped Franciscan Health System eliminate all of the Type I deficiencies it had in the past, said Joseph Wilczek, president and chief executive officer of Franciscan Health System. "Catholic Health Initiatives’ interim survey instrument was very helpful to us, and Nancy’s ability to interact with our staff made a tough task pleasant," said Wilczek. While helping market-based organizations prepare for their surveys, Lima and Joanie Cox, director of clinical performance improvement, compiled a list of "good things" identified by JCAHO surveyors. "The list addresses many topics, from staff training to interdisciplinary care plans and spiritual assessments," said Lima. "JCAHO surveyors are trained to identify things that contribute to the environment of care as well as things that need improvement." One of the surveyors commented on how impressed he was that Catholic Health Initiatives’ market-based organizations recognize the uniqueness of each patient and provide individualized care to meet their physical and spiritual needs. The 2003 round of surveys began with Catholic Health Initiatives’ fifth annual Pre-survey Update Conference, held in Las Vegas, Nev., February 3—5. This year, in addition to Lima and Cox, Mary Osborne, director of clinical performance improvement, will support market-based organizations as they prepare for and follow up on JCAHO surveys. "We’ll continue to provide individualized support to the market-based organizations," said Cox. "There’s no ‘one size fits all’ solution to preparing for a JCAHO survey, and we’ll continue to provide the assistance that each organization needs most." Jeffrey Drop, president and chief executive officer of St. Anthony Hospital, Pendleton, Ore., appreciates the custom approach taken by Catholic Health Initiatives’ clinical performance improvement team. "They told us not only what to expect during the survey, but how to respond," he said. "We wouldn’t have received the score we did without their help." To request a copy of the "good things" list, contact Joanie Cox at joaniecox@chi-caritas.org or Nancy Lima at nancylima@CatholicHealth.net.