Insider North

Under the gun: Joint Commission surveyors stopped employees in the hallways to ask questions about their work, procedures and policies. One of those interviewed, Danielle Adair, registered nurse in PVH’s intensive care unit, was singled out for doing a remarkable job with her responses. Surveyors asked her about a patient under her care. They also inquired about patient restraint policies and transfer times from the ER to ICU.

They came. They saw. They researched. They interviewed. They judged. And they were impressed.

In simple terms, that’s the story of what happened with The Joint Commission surveyors who in mid-July spent five days at Poudre Valley Hospital and four days at Medical Center of the Rockies. They reviewed hundreds of documents and interviewed employee after employee, all in a quest to discover where improvements can be made.

They found some areas for improvement. They always do, regardless of which of the 19,000 hospitals or other health-care organizations they survey throughout the U.S. Surveying is, in part, done for accreditation as a condition of being certified by the federal government for participation in the Medicare and Medicaid programs. Some insurance companies also require accreditation as a condition of being in their network and reimbursement services.

But at their end-of-the-survey exit conference with the Senior Management Groups at MCR and PVH the surveyors said they were happy with what they found throughout the organization. They used descriptions like “phenomenal job” and “one of the best facilities seen in a long time” and “in the top 1 percent of the hospitals we have ever surveyed.”

Glowing praise, indeed. Especially when it’s taken into consideration that the survey team suddenly showed up unannounced—well, not quite unannounced, that is.

It used to be that The Joint Commission scheduled surveys in advance with organizations. This gave employees time to scurry around and locate this or that patient-care record or document, update meeting minutes here and there, ensure that all employees knew what RACE means, and, among many other things, check in refrigerators to make sure required thermometers are in place to measure the temperatures.

Needless to say, this advanced warning put additional pressure on employees, who suddenly became jittery, often staying up all night to make sure everything was just right and ready for the surveyors.

But several years ago The Joint Commission shifted course and decided to arrive at an organization out of the proverbial blue and conduct the survey. That means hospitals must always be survey-ready. That’s a good thing, ensuring that health care providers are always ready. 

Since The Joint Commission can now show up unannounced any time between 19 and 36 month after the last survey, Ric Detlefsen, director of Quality Resources, which is responsible for UCHealth survey-readiness in northern Colorado, has been religiously checking the agency’s website early every Monday morning to find out which health-care organizations will be surveyed in the coming week.

The Monday of the survey at PVH and MCR the website reported that surveyors would be here in 30 minutes, at 8 a.m. Detlefsen hurriedly activated a pre-arranged communication tree to ensure that management and frontline staff knew surveyors were on the way.

Regardless of the short notice, the survey went extremely well, says Kevin Unger, PVH president and CEO. “This was the smoothest survey I’ve ever seen,” observes Unger, who joined the organization in 2001.

George Hayes, a veteran of two dozen years as a leader with a major Kansas City hospital and, since 2007, MCR's president and CEO, was delighted with how impressed the surveyors said they were. “They were very complimentary on how well our staff members were prepared to respond to their inquiries and provide information, and how open, welcoming and competent our employees are.”

Detlefsen, normally a calm guy with a sharp wit and wry sense of humor, was downright gleeful after the surveyors spoke their glowing exit report to senior management. “The one change that we’ve seen in the Joint Commission is that surveyors are much more consultative than in the past,” Detlefsen says. “They offer advice on how to make improvements and they give you good ideas.”

It used to be, back in the far day, that surveyors were, quite frankly, overly tough. PVH once was inspected by a crew of ornery surveyors who passed out Type 1 citations—that’s what the worst citations used to be called—like they were giving away candy on Halloween. Not long after that, the hospital president was suddenly gone frm his position.

Now, surveyors categorize their citations in two ways. One is called “direct impact,” where an issue might have an immediate adverse effect on patient care. The other is “indirect impact." which could have a lesser impact on patient care in some way or another. For example, one indirect impact citation involved a bin for soiled linens that was larger than the required 32 gallons.

PVH had six direct and seven indirect impact citations; MCR, five and five. Each hospital received a 20-page detailed report of what was found during the survey. A lot of what is needed is to enhance certain work processes and better educate the staff, Detlefsen points out.