JCAHO Survey Preparation

Healthcare organizations are experiencing the impact of the JCAHO's Agenda for Change as it relates to the accreditation standards and the survey process. Standards are no longer department specific but are organized by the functions most critical to patient care. Surveys are far more interactive, with the surveyors visiting at least 50% of the patient care areas in the organization; surveyors are evaluating and scoring the standards as a team; and the focus of the survey is shifting from the capacity to perform to actual performance.

Healthcare organizations need to orient their staffs to the standards and prepare them for a participative survey process.

Educational Presentations

To assist healthcare organizations with their preparation, MHEI offers a variety of educational presentations and seminars on which can be conducted on an in-house basis. Presentations can be tailored to specific audiences and time frames. Our most popular presentations are:

1. JCAHO Standards Update
2. Walk Through: A Typical JCAHO Survey

Pre-Survey Consulting

Our pre-JCAHO survey process incorporates document review, interviews, reviews and site visits. Our experienced team consisting of a nurse, quality management professional and physician will assess your organization's readiness for your upcoming survey. We recommend that our pre-survey be scheduled at least 6 months to one year before your next anticipated survey. The pre-JCAHO Survey Consultation Process provides:

• Up-to-date information on changes in the standards and survey process,
• an opportunity to participate in a mock survey process and interact with our survey team,
• an evaluation of your compliance with the AMH standards, and
• a verbal summation of findings at an exit conference addressing areas of positive performance, non-compliance, and strategies for achieving compliance.

The Pre-Survey Process can be conducted in several formats. The most common formats are either a two-day educational version or a four-day simulated survey.

Two-Day Educational Survey

• Condensed version, provides sampling of typical survey activities
• Focused on critical standards, past areas of non-compliance with JCAHO identified trouble spots
• Stresses education and orientation to the survey process

Four-Day Simulated Survey

• Simulated version, addressing all typical survey activities
• Comprehensive assessment of all AMH standards
• Stresses evaluation of standards compliance along with education and orientation to survey process

If you would like to discuss any of this activity, please call Geri Mendelson at (410) 321-6200 or send her email (gmendelson@mhaonline.org)