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In This Issue:
The JCAHO survey can be thought about in the following three sectionsASK YOURSELF: “Are You Ready for JCAHO?”
While it may seem like just yesterday to many at BWH, it has been nearly three years since the last Joint Commission on Accreditation of Healthcare Organizations (JCAHO) survey was conducted at the hospital. An enhanced JCAHO survey with a new focus on patient safety and quality of care will take place in January of 2004 and a full team effort is needed to help bring about success.
BWH will be one of the first organizations surveyed with JCAHO's new Priority Focus Process (PFP). As a result, JCAHO efforts will focus on issues most relevant to patient safety and quality of care. Also new in 2004 will be the use of Tracer Methods in which surveyors randomly audit patients' medical records and essentially retrace the patient's steps in the care process by observing and interviewing staff in the areas in which the patient received care.
All organizations that seek accreditation by JCAHO are surveyed every three years. The exception to this cycle is the laboratory accreditation surveys, which take place every two years. As many may recall, BWH's lab JCAHO survey took place in March 2003 and received a perfect score. Next January, surveyors will again be on-site at BWH for five days visiting clinical areas and interviewing employees and staff about the organization and patients about their experiences. JCAHO accredits approximately 17,000 health care organizations including hospitals, rehabilitation facilities, psychiatric hospitals, nursing homes, ambulatory care providers and clinical laboratories. Organizations that are accredited are deemed to be compliant with the Conditions of Participation, and eligible to participate in the Medicare and Medicaid Programs.