JCAHO to shift to unannounced surveys by 2006

Sunday, April 6, 2003

April 7, 2003

OAKBROOK TERRACE, Ill. - The Board of Commissioners of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced last week its intent to begin conducting all regular accreditation surveys on an unannounced basis beginning in January 2006.

Unannounced surveys will be pilot-tested in volunteer organizations during 2004 and 2005.

Joint Commission plans to introduce a substantially new accreditation process beginning in January 2004 have been widely discussed with accredited health care organizations during the past year. The proposal to transition to unannounced surveys — approved by the Board of Commissioners at its March 28-29, 2003, meeting — was a direct outgrowth of those discussions.

“The new accreditation process — dubbed Shared Visions – New Pathways — creates the expectation that each accredited organization be in compliance with 100 percent of the Joint Commission’s standards 100 percent of the time,” said Dennis S. O’Leary, M.D., president, JCAHO. “Organization leaders whom we talked to not only agreed with this expectation but further suggested that the next logical step would be the introduction of unannounced surveys.”

“Shared Visions-New Pathways provide strong incentives for organizations to provide safe, high-quality care at all times; such organizations should be prepared for a JCAHO survey at any time,” says Bernard L. Hengesbaugh, Chairman and Public Member, Joint Commission Board of Commissioners. “Being ready for a thorough survey at any time is a logical extension of the accredited organization’s commitment to continuous improvement.”

During 2004, the Joint Commission expects to initiate pilot testing of the unannounced triennial survey process in up to 100 hospitals that have volunteered to be among the first participants. Four multi-hospitals systems and alliances — Ascension Health, Tenet Healthcare, Veterans Health Administration and North Shore-Long Island Jewish Health System — have committed to having a number of their hospitals participate in unannounced triennial surveys in 2004 or 2005 (see accompanying list).

In 2005, JCAHO will continue to conduct voluntary unannounced surveys on a limited basis – opening up the option to all types of accredited organizations, and then transition to a completely unannounced survey program in 2006. During this period, JCAHO will work closely with its various advisory groups, accredited organizations and other stakeholder groups to gain their input and progressively refine the new accreditation process and smooth the transition to unannounced surveys.

The Joint Commission plans to continue to conduct one-day random, unannounced surveys in an annual 5% sample of the health care organizations it accredits through the end of 2005. After that time, random unannounced surveys will be discontinued.

Details about the plan to introduce unannounced triennial surveys will be shared with accredited organizations in the coming months through educational programs, newsletters and other outreach activities.