Ask Yourself: Are You Ready for JCAHO?- BWH Bulletin - For and about the People of Brigham and Women's Hospital
Ask Yourself: Are You Ready for JCAHO?- BWH Bulletin - For and about the People of Brigham and Women's Hospital
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March 20, 2000
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In This Issue:
Major Step Towards
Ask Yourself: Are You Ready for JCAHO?
BWH Celebrates Social Work Month
Baby Faire to offer information, fun, and prizes
Pike Notes
World-Class care is just down the hall
Kruger to Join BWH
ProTech Students
WH has begun counting down to its next triennial Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey, scheduled to take place in January 2001. During JCAHO’s full-hospital survey—a comprehensive review of hospital programs, and policies and procedures—surveyors will spend five days visiting clinical areas and interviewing employees and staff. JCAHO will also conduct the biennial survey of BWH labs during this time. JCAHO is an independent, not-for-profit organization that evaluates and accredits more than 19,500 health care organizations in the United States including hospitals, health care networks, managed care organizations, and other entities that provide home care, long-term care, and laboratory and ambulatory care services. The goal of JCAHO is to improve the quality of health care provided to the public, and it does so by accrediting health care organizations that qualify after a thorough inspection. During a survey, hospitals and other organizations are measured against standards in important functions. These standards can be accessed electronically under Partners Applications – CAMH99. According to Karen S. Nelson, director of Corporate and Regulatory Compliance, “Our early and thorough preparations for our JCAHO survey directly contribute to our successes. During our last triennial survey, we effectively demonstrated our excellence in key functions such as leadership, patient care, performance improvement, and maintaining a safe environment. In doing so, BWH was recognized for this exemplary performance and was awarded ‘Accreditation with Commendation,’ the highest an organization could receive at that time.” Although JCAHO accreditation is voluntary, most hospitals seek accreditation because Medicare, Medicaid, and many state agencies and third-party payors require JCAHO accreditation for participation. JCAHO’s recent ruling allows unannounced surveys anywhere and at almost anytime during any given accreditation period, including the current accreditation period. “Continuous readiness is our goal,” says Matt Van Vranken, Chief Operating Officer. “Although we will experience increased activity surrounding JCAHO’s 2000 Survey, we should all remember that BWH’s organizational practice is to maintain a baseline of ongoing compliance.” As always, BWH policies are available through the Administrative Policies Manual located on BICS. Take this opportunity to refresh your memory about these important policies. Also, look for “Finishing Touches” (3rd edition), the hospital’s guidebook on the JCAHO survey, that will be distributed to all supervisors in late summer and will contain practical information on preparing for JCAHO. In the coming weeks, Bulletin will publish regular updates on JCAHO. For more information, contact one of the JCAHO Prep Team (the PREPAIRE Team) members: Karen Nelson, Cathy Breen, Pat Reid-Ponte, Diane Hanley, Dee Dee Mariano, Susan Ravagni, Tonya Miltier, Richard Giardina, Janice Rogers, and Rebecca Silver.