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                        JeffNEWS, August 16, 1994
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JCAHO Coming to Town
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Some events, like birthdays, happen annually. Others, such as leap year 
and visits from the Joint Commission on the Accreditation of Healthcare 
Organizations (JCAHO), happen less frequently. Although we won't see 
another leap year until 1996, for Jefferson, a visit from JCAHO is just a 
flip-of-the-calendar-page away.

JCAHO surveyors will be visiting Jefferson Hospital sometime this fall 
for our once-every-three-years site survey. JCAHO evaluates hospitals and 
healthcare organizations to ensure that they carry out certain 
responsibilities as a provider of care and to improve the quality of that 
care. Hospitals strive to receive JCAHO's "seal of approval" because it 
enhances community confidence and helps them attract and recruit qualified 
medical staff and professionals. In addition, some payers won't contract 
with unaccredited hospitals. 

As in the past, surveyors will meet the administrators and department 
chairpersons, but this year's visit has a slightly different twist. It will 
be more intensive and much more interactive. The surveyors will spend a 
large amount of time conducting scheduled and unscheduled interviews with 
employees in patient care areas and members of the medical staff. During 
these interviews, participants will be expected to explain the 
interdisciplinary, hospitalwide policies and procedures for how care is 
provided and their own role in that process. Individuals may also be asked 
questions about our mission and how they contribute to our mission as they 
do their job, fire safety and disaster procedures, quality improvement 
initiatives and other relevant topics. 

Since many employees may be unaccustomed to meeting with JCAHO 
evaluators, a survey preparation team is working with department managers 
to be sure that every employee is prepared to answer the surveyors' 
questions during an interview. The committee is also reviewing the 
requirements of the JCAHO and assembling the necessary documentation the 
hospital must provide to demonstrate that we are in  compliance with JCAHO 
standards. 


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Information provided by:  Editor, JeffNEWS
                          (215) 955-6204
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