February 2000

Corporate Summation Presents Integrated JCAHO Findings


Leaders of the teams that conducted Catholic Health Initiatives’ first multihospital system survey by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently presented integrated findings from their 1999 surveys of market-based organizations. The team leaders presented the findings during a corporate summation conference held at the Denver national office.

"The JCAHO team leaders, Lee Trick, MD, and Dale Brown, RN, pointed out a number of areas in which specific Catholic Health Initiatives market-based organizations perform exceptionally well," said Nancy Lima, director of performance improvement for Catholic Health Initiatives. "They also made several suggestions regarding areas in which we can make improvements. The facilitation of these improvements will be a focus of the Clinical Leadership Resource Group as we work with the market-based organizations this year."

Lima noted that one of the market-based organizations surveyed – Mercy Medical Center of Nampa, Idaho – received accreditation with commendation, which means it achieved a score of 90 or above with no Type I recommendations. "It’s a wonderful feather in Mercy’s cap," she said.

Because Catholic Health Initiatives has elected to be surveyed as a multihospital system, the JCAHO teams that survey market-based organizations retain the same leaders during each cycle of market-based organization surveys. The team leaders lend continuity and consistency to the surveys and integrate the findings. "It was helpful to us that the surveyors were already familiar with the structure of our system when they came here," said Greg Wozniak, president and chief executive officer of Nazareth Hospital, Philadelphia, Pa., and St. Mary Medical Center, Langhorne, Pa.

The multihospital system survey option also provides new opportunities for market-based organizations to prepare for their surveys. This year, as in 1999, Catholic Health Initiatives sponsored a pre-survey update conference for JCAHO leaders at market-based organizations. The conference, "Insights to Survey Success," was held February 14-15 in Las Vegas, Nev. "The JCAHO leaders were able to meet the nurse and physician surveyors who will conduct their surveys and ask them questions," said Lima. "Last year, the attendees took information from the conference back to their facilities and were able to implement new practices or procedures well before their survey dates." This year’s attendees also heard helpful "war stories" from some of the market-based organizations that were surveyed last year.

Lima and Joanie Cox, directors of performance improvement, are available to help market-based organizations prepare for JCAHO surveys. They also maintain an active e-mail network during survey periods. "Either Joanie or I are present during each survey to assist the market-based organization staff and take notes," Lima said. "We e-mail our notes to market-based organizations that have surveys coming up as well as those being surveyed in other years. This real-time information gives market-based organizations a feel for what the surveyors are looking for in specific areas and helps with ongoing compliance activities. We also communicate the surveyors’ positive comments about particular processes or policies and provide contact people for other market-based organizations to consult as resources on specific topics."