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The
Results of a Recent JCAHO Survey at a Hospital, 2001
One of the 300 + bed hospitals in our D/10
networking group in Philadelphia went through JCAHO in February, 2001. I
thought you might be interested in the details of what it was like. Caveat
- there is no guarantee that a particular surveyer will conduct himself or
herself the same way each time.
Surveyor Profile
Phillip Todd, approx. 50 years old from the South,
polite, not intimidating, appreciative, rides a Harley Motorcycle, loves
cholcolate, likes bottled water, did appreciate catered meals and snacks
during the day, did not use the "White glove" approach at this
hospital, this time.
Time spent in non-clinical portion of food service -
30 minutes
What did he say and do?
-
Picked up and dented a can in the storeroom and
handed it to the Director and asked about the dented can procedure.
The Director explained the procedure and placed the dented can on the
"to be returned" shelf - NO citation.
-
Found a "bug zapper" electrical unit
that was hung on a wall, not in use, and very dusty. The client
confessed, "we don't use it anymore." The Surveyor said,
"probably should remove it." The client removed it within 24
hours. No citation.
-
The Surveyor wanted the pot and pan sink
sanitizer water to be tested regularly for appropriate sanitizer
strength using a "test strip". The Surveyor didn't think
that it was good enough for the sanitizing system to be regulary
checked by Ecolab. Evidently the Surveyor would be more impressed with
the sanitizing water being tested every day, or maybe even every time
the water is changed - No citation.
-
Did not go deeply into HACCP compliance. Did
check temperature logs - especially of food being shipped offsite. Did
check Ecolab reports and 2 years worth of hood cleaning records.
-
Did not look at or ask for recipes.
-
Although trayline was running, he didn not check
temperatures or look very close.
-
Did not talk to Food Service Personnel other
than the Director.
-
Did not check cafeteria.
-
Did not go deeply into policies and procedures.
Asked about 1 or 2 but didn't look at them.
-
Did not actually walk into the cooks area. Just
observed from the edge of the area. Hence, he didn't open drawers,
etc., in the cooks area.-
Did check closely
for dates and labels everywhere.
-
Did not check to insure that dishes were really
clean by pulling out a bunch of entree plates.
-
Did not check to see if the cleaned pots and
pans on the shelves were dry.
-
Did not look under storeroom shelves for debri
or pest droppings.
-
Met with all the department heads to ask a few
questions, e.i.,
-
Do the employees have input on capital equipment
needs? If so, how do you get the input?
-
What is the method used for department heads to
communicate with each other?
Bottom line - No citations
What did the hospital do to get ready?
There was the equivalent of about 3 "mock"
surveys prior to the JACHO survey:
-
First - I did a mock survey during a routine
D/10 follow up visit.
-
Coincidentally, the State Department of Health
paid a visit several weeks prior. The pressure of getting ready for
the state helped them get ready for JCAHO.
-
One week prior to the JCAHO survey I sent in one
of my D/10 team members who specializes in Mock JCAHO inspections.
This took one day.
Comments
This was a relatively easy survey (inspection)
compared with some of the others I've been involved in. My advice is to
prepare for a "white glove" inspection from someone who hasn't
slept for a week, and is a total monster. Leave no stone unturned and
start getting ready 90 days in advance. 30 days prior to JCAHO, start
doing daily inspections, (surveys audits) of every square inch of your
kitchen. Remember, if your kitchen looks "sharp as a tack", then
the perception will be that you've got your act together. But, if things
look messy, cluttered, disorganized, and especially unclean - look out.
Once they smell blood, they may look so deep that you could be in trouble.
The closer they look, the greater the chance of a citation.
Of course the ideal, winning thing to do is to
conduct your operation in such a way as to always be ready for JCAHO. But
due to turnover, personnel shortages, construction and other factors, most
FSD's are unable to operate in an ideal mode.
Critical Comment from the Food Service Director
"We looked sharp and I feel like it helped us a
lot".
I hope you find this info. helpful. After you go
through a survey, call me and I'll make up another one of these profiles
to share. The more information we have, the better our chances for
"0" defects, and a perfect survey.
Good luck,
Don Miller, R.D., C.E.C.
Nancy Yezzi, R.D., L.D.
Bill Klein, C.I.C.
Success Coaches
Don Miller and Associates
346 Crestview Drive
Bonita, CA 91902
(619) 656-2100 PST
(619) 656-1321 fax
chefdon@cox.net
http://www.chefdon.com
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