September 1999

JCAHO to Conduct Random, Unannounced Surveys


Catholic Health Initiatives is well into its first year of a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) system-wide survey, which will take three years to complete. To help market-based organizations prepare for their surveys, Catholic Health Initiatives national staff members Joanie Cox and Nancy Lima, directors of performance improvement, act as internal JCAHO consultants. Cox and Lima are available to assist market-based organizations with preparations and can be present for the actual surveys. "As we expected, the JCAHO surveyors are fair but are paying more attention to details than in years past," said Hal Ray, MD, senior vice president and chief medical officer for Catholic Health Initiatives. "Commendations are increasingly rare. Some people believe this is due to recent criticism of the JCAHO process by the Office of the Inspector General, but JCAHO denies this allegation." Facilities must be in compliance at all times Another significant change in the accreditation process is that JCAHO is planning to conduct random, unannounced surveys. Five percent of accredited organizations will be selected at random for these surveys, which can occur from nine to 30 months after their triennial surveys. "There will be no advance notice, nor will the organizations selected know the scope of the survey in advance," said Ray. "This means that all Catholic Health Initiatives facilities must make sure they are in compliance with all JCAHO standards at all times." While some market-based organizations have requested exclusion from the JCAHO accreditation process due to a perceived lack of value and the costs associated with the surveys, Ray said that all acute care facilities within Catholic Health Initiatives should obtain JCAHO accreditation. "Under some unusual circumstances, long-term care facilities may opt out of the process if they obtain the approval of their group president and the lack of JCAHO accreditation will not affect any third-party payments," said Ray. He also noted that state accreditation requirements are expected to remain the same.