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What the Survey Process Expects of Your Organization

NCJ Number
194358
Journal
Joint Commission Perspectives Volume: 21 Issue: 12 Dated: December 2001 Pages: 6-7
Editor(s)
Helen Fry
Date Published
December 2001
Length
2 pages
Annotation
This article discusses the accreditation survey process of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Abstract
The events of September 11, 2001, have necessitated a greater focus on emergency management planning and an increased flexibility and applicability of the plan. Organizations need to look closely at their plan as will JCAHO surveyors, to ensure that it applies to a variety of disasters on many different scales. During various functional interviews in an accreditation survey, JCAHO surveyors assess how an organization plans and implements its emergency plan; how the plan applies to a variety of possible events; and whether staff at all levels has been trained in their roles and responsibilities in the plan. Leaders need to work together to address the needs of the organization and its community. Specifically, they must determine the scope and resources, vulnerability, command structure, and implementation of the plan. They may need to rapidly expand clinical and nonclinical staff. During visits to care units, surveyors ask staff how they are involved in planning, designing, and implementing the emergency management plan. Staff must be able to answer questions about the education they have received about recognizing hazards; the types of orientation and training regarding roles and responsibilities; and whether the unit participates in emergency-preparedness drills regularly. Involving clinical staff (nursing or medical staff leaders) in implementing the plan is key because they directly affect the safety and care of patients through the plan's use. The surveyors address how the emergency plan is integrated with other environmental care (EC) functions. The most intensive assessment of an organization's plan occurs at this time. Some issues that need to be addressed by the organization regarding this are clearly defined staff roles for external emergencies; how to contact community response agencies during a disaster; and evidence that the external emergency plan has been implemented in the past 12 months.