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:
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.