Good News, Bad News for System Surveys

By Ruth Elzer, RN, MS

The news from the Joint Commission’s Hospital Executive Briefings is always a mixed bag of information. This year is no different. Hospitals surveyed as part of a healthcare system, though, should brace themselves for a big change.

Ann Scott Blouin, Executive Vice President for Accreditation and Certification Operations at the Joint Commission, announced yesterday that hospitals currently undergoing the system survey option will experience changes in their survey processes.

Currently, hospitals surveyed as a part of a healthcare system begin their surveys with an orientation and opening conference that surveys standards that apply to all sites within the system. The surveys of individual hospitals within the system then follow in subsequent weeks using common surveys, when possible. This process provides some “advanced warning” to hospitals in the system, allowing them to anticipate surveyor arrival and be prepared for surveyor “preferences.”

However, by July 15, 2010, the Joint Commission will retool the system survey in the following key areas:

• Surveying the shared services and functions together, much like in the past
• Immediately conducting concurrent surveys in each of the hospitals within the system
• Providing the assistance of a field operations representative from The Joint Commission to assist with the survey. The field operations representatives are also the individuals who commonly provide input into the evaluation of surveyor performance. The degree to which these representatives will be “watching” the surveyors is unknown.

These significant changes in the approach to system surveys will likely cause hospitals to reconsider the system option. The Joint Commission will contact health systems in the coming months, urging them to make decisions about how their component organizations will be surveyed.

Systems and individual hospitals should consider several key points when making their decisions about the system survey option.

• CMS and The Joint Commission will align to provide one accreditation decision for each Medicare entity (one Medicare number=one accreditation decision). In systems with only one Medicare number, this may raise the risk to the entire system when one hospital’s performance lags behind that of the others.
• Concurrent surveys will likely multiply, rather than add to the number of individuals needed to “host” and manage the survey process. System quality representatives will be spread thin during a visit and have less ability to share information between hospitals.
• Concurrent surveys will eliminate the advantage that system surveys previously held in using the results of the first survey to improve results of subsequent surveys.

These factors, in addition to the cost associated with the system survey option, should be thoroughly investigated before hospitals agree to continued survey as a part of their health systems.