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Three hospitals' survey experiences.

R A Higgins1, B Elenteny, B Collins

  • 1Chinese Hospital, San Francisco, CA, USA.

Journal for Healthcare Quality : Official Publication of the National Association for Healthcare Quality
|December 9, 1995
PubMed
Summary
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The Joint Commission updated hospital accreditation standards, focusing on patient care, staff competency, and process improvement. Thorough preparation is crucial for successful surveys under the new Agenda for Change.

Area of Science:

  • Healthcare Administration
  • Quality Improvement in Healthcare
  • Hospital Accreditation Standards

Background:

  • The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) implemented significant changes to its accreditation standards and survey processes.
  • These revisions, part of the Agenda for Change, emphasize a cross-functional approach to healthcare delivery.

Purpose of the Study:

  • To outline the major alterations in The Joint Commission's standards and survey process.
  • To highlight key areas of focus for surveyors under the 1994 Accreditation Manual for Hospitals.
  • To underscore the importance of preparation for hospital accreditation surveys.

Main Methods:

  • Review of the 1994 Accreditation Manual for Hospitals.
  • Analysis of surveyor focus areas including patient care, restraint policies, conscious sedation, staff competency, and process improvement.

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  • Emphasis on the document review session as a critical component of the survey process.

    • Main Results:

    • Surveyors evaluated critical patient care issues, including restraint policies and procedures.
    • Uniform performance of processes, specifically conscious sedation, was a key focus.
    • Staff competency and continuous process improvement were central to the evaluation.

    Conclusions:

    • Hospitals must prepare thoroughly for document review sessions to ensure survey success.
    • Understanding and adherence to the revised JCAHO standards are essential for accreditation.
    • The Agenda for Change necessitates a comprehensive and integrated approach to hospital quality and safety.