NY-NJ Chapter LogoNewsletter
Winter 2002

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From the Editors

From the Chair

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Brave New World

In the Literature

Technology Review

Hospital Library Notes

RML Update

In Memory of Winifred Lieber

HLSP Update

"To The Editors"

Special Feature
by Luda Dolinsky



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The Newsletter is published for the members of the New York-New Jersey Chapter of the Medical Library Association.

Editor of this issue:

William Self, Medical Library Center of New York, 7 East 102nd St., 7th Floor, New York, NY 10029, S-1, Phone: 212-427-1630, Fax: 212-860-3496, E-mail: wself@mlcny.org.



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Posted 3/15/2002
2002 NY-NJ Chapter of the Medical Library Association
Hospital Library Notes
Preparing for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Survey

by Robert M. Joven
Director, Hospital for Joint Diseases Library
jovenr01@library.med.nyu.edu


Healthcare Organizations go through an on-site survey by a JCAHO survey team at least every three years to earn and maintain accreditation. Achieving accreditation means meeting national standards set by health care professionals. Taking part in the survey also sends a strong statement to the community about the organization's efforts to provide the highest quality services. The hospital librarian is an active participant of this survey and will participate in interviews with JCAHO surveyors. This article will provide simple tips for preparing and surviving the JCAHO interview. In particular, we will look at ways in which the hospital librarian can effectively and efficiently prepare for the survey.

Much time and money are spent preparing for this visit. A successful survey requires an organizational effort, with individual departments and professionals working together. Hospital librarians will be involved in interviews for the Information Management team as well as additional interviews depending on the librarians' involvement in other activities within the organization. An interview may also occur for the library or Resource Center. Planning ahead is important in order to achieve a successful JCAHO visit.

What can the hospital librarian do to prepare? Begin with reviewing existing library policy and procedures to make sure they address basic issues that will be raised during the interview process. These areas to be examined are:

  • Access to the Library - Who can use it and how do they access services including remote access to databases?
  • Collection Development - Is the collection current and up-to-date? How do you find out from users what they need in the collection?
  • Needs Assessment - How do you find out what your users want or need from the library?
  • Quality Improvement - What mechanisms are in place to continuously evaluate and improve services?

If necessary, revision to the policies and procedures may be performed to comply with the unique and changing needs of your organization.

Your next step is to gather the evidence of compliance with the standards. The surveyor may ask to see the library's policy and procedures manual, written needs assessment, quality improvement plans, and meeting minutes. These materials should be organized and readily available during the interview to support your discussion. Also, make certain the library has an updated copy of your hospital's Administrative Policy Manual. The surveyor may ask to see this as part of the library visit.

Your organization will conduct mock surveys in preparation for the actual visit. The librarian should participate in mock surveys to determine readiness and compliance. Hospital librarians in other institutions who went through JCAHO survey in the past are great resources. Consulting with them will provide you with useful tips on how to successfully succeed in this survey.

There are other resources available to help you prepare for the survey. The Medical Library Association published Standards for Hospital Libraries, and Librarian's Guide to JCAHO Accreditation to broaden your understanding of standards requirements. The Joint Commission Resources website [http://www.jcrinc.com/] offers a variety of manuals, books, periodicals, and other products to help health care organizations participate successfully in the accreditation process. The JCAHO Web site, at www.jcaho.org, provides answers to frequently asked questions. Articles written by hospital librarians and other professionals on survey standards are helpful resources to plan for this event as well.

The JCAHO visit should not be viewed as an experience to be survived but rather an opportunity to enhance performance. Hospital librarians, as an active participant of the survey, need to plan for this event. Evaluation of library policies, organization of documentation to show compliance, participation in pre-survey activities, consulting with colleagues, and reviewing published resources in preparation for the survey will effectively provide the hospital librarian with tools needed to guarantee a successful JCAHO survey.

Suggested Readings:

  • Dalrymple PW, Scherrer CS. Tools for improvement: a systematic analysis and guide to accreditation by the JCAHO. Bulletin of the Medical Library Association. 86(1):10-6, 1998 Jan


  • Bradley J. Management of information: analysis of the Joint Commission's standards for information management. Topics in Health Information Management. 16(2):51-63, 1995 Nov


  • www.jcaho.org, Joint Commission on Accreditation of Healthcare Organizations' Website


  • Standards for Hospital Libraries, http://www.mlanet.org/publications/standards/hospital/index.html


  • Librarian's Guide to a JCAHO Accreditation Survey, http://mlanet.org/resources/jcaho.html