The Fact on Fiction from the February 2005 issue of Perspectives

Organizations not affiliated with the Joint Commission produce products and sponsor education programs related to Joint Commission accreditation. At times, the information provided in these products and programs is confusing, misleading, or inaccurate. The Fact on Fiction column identifies this misinformation with the intent of preventing confusion and correcting misperceptions in the field. This column is included in Perspectives on an “as needed” basis, whenever misleading or inaccurate information on Joint Commission initiatives is published. Questions about Joint Commission initiatives can be directed to perspectives@jcaho.org or SharedVisions@jcaho.org.

A number of consultants and publications have been providing advice about how to “prepare” for the new Joint Commission survey. For example, the November 2004 issue of Briefings on JCAHO includes a book excerpt (The JCAHO Survey Coordinator’s Handbook, Fifth Edition) centering on creating documentation binders for surveyors to review during a Joint Commission survey. The excerpt suggests creating a binder for each surveyor that contains all the documents (for example, policies and procedures) a surveyor might request during patient tracers.

This advice is not in keeping with the goals of the Joint Commission’s new accreditation process. Of course, the Joint Commission does not require organizations to have all their documentation in a binder(s) ready for the surveyor to review. While an organization creates many documents for its own purposes, there is no reason—in fact, it is a waste of time—to create documents or books of documents just for the Joint Commission. An organization will review these documents itself during its Periodic Performance Review and work with the Joint Commission’s Standards Interpretation Group to correct any deficiencies. During the on-site survey, surveyors will look at how the organization executes its policies and procedures. It is possible, in a small number of instances, for a surveyor to request a document during the survey, for example, if execution is inconsistent. If so, the organization will have plenty of time to retrieve what the surveyor is requesting.

The book excerpt goes on to suggest “a smooth survey requires advanced planning with current, organized information about your hospital available to surveyors” and “leav[ing] yourself enough time to gather and prepare the original documents before the surveyors’ next visit.” While this advice was of some value before January 1, 2004, it is not aligned with either the intent or the reality of the Joint Commission’s new accreditation process. The Joint Commission focuses on improving the safety and quality of care provided through continuous standards compliance. Organizations should not be preparing for survey, but focusing on providing safe, high-quality care on a continuous basis. The spirit of the new accreditation process is that the organization invests its time and resources (including those for any consultants) in improving the quality and safety of care, rather than preparing for the Joint Commission’s survey. In fact, the process of preparing for a survey will become impractical in 2006, when surveys will be unannounced. For additional information on unannounced surveys, please see “Unannounced Survey Process on Track for Full Implementation in 2006” in the January 2005 issue of Perspectives. For additional information on the Joint Commission’s new accreditation process, please see “The Launch of Shared Visions–New Pathways” in the January 2004 issue of Perspectives.