Always Prepared – A JCAHO Story

When Coney Island Hospital became the first public hospital in New York City to have an unannounced triennial visit this year by JCAHO, the Joint Commission on Accreditation of Healthcare Organizations, no one was caught by surprise.

After all, when JCAHO announced in 2004 that it would change its survey process by making impromptu rounds beginning in 2006, four HHC facilities volunteered for the pilot, confident they would meet and exceed the national oversight group’s quality and safety standards.

Terry Mancher, Chief Nurse Executive at Coney Island, has experienced many successful JCAHO reviews over the years but does not miss the stress that hit days before the scheduled inspections.

“Once you found out what day they were coming there would be a mad rush to get things in order – last minute spring cleaning of a sort,” noted Mancher. “Now we strive to be in a constant state of readiness.”

That constant vigilance by everyone on Coney Island's team earned more than a standard nod of approval. Several days after the survey was completed, JCAHO wrote a letter to the ICU Head Nurse to praise her for a presentation she did on an Infection Control case. “I’ve never heard of anything like that happening,” added Mancher.

In addition to the new unannounced visits, JCAHO has also revised its review process. Surveyors have begun to follow a specific method to trace how care was provided to individual patients across multiple units and departments.

"It is an effective process which identifies whether a patient received the right care in the right manner by the right practitioners at the right time," said Caroline Jacobs, Senior Assistant Vice President of Patient Safety, Accreditation & Regulatory Services. "It's a challenging approach and completely consistent with our patient-centered philosophy of care,” added Jacobs.

Meanwhile three more HHC facilities have also had their “Welcome JCAHO” mats out this year. Sea View nursing home turned in an outstanding performance during their August visit, earning special notice for their improvements to patient safety. Lincoln also received full accreditation after their successful August survey and Kings County expects their surprise visit any day now.