ACSM's Health & Fitness Journal

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ACSM'S Health & Fitness Journal:

Did Someone Say "JCAHO"?

Lynch, Daniel J. M.S.

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Dan Lynch, M.S., has been in the medically based health and fitness business for 33 years. He is currently the director of health and fitness for Holy Name Hospital in Teaneck, New Jersey. You can reach him at

If you work in a hospital environment, just mention the word JCAHO (pronounced "JAYCO") and you might send shivers up and down a few administrators' spines. JCAHO is short for Joint Commission on Accreditation of Healthcare Organizations ( Listed on their Web site are the Accreditation Programs they offer, covering the following health care service lines:

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* Ambulatory Care

* Behavioral Health

* Critical Access Hospitals

* Home Care

* Hospitals

* Laboratory Services

* Long Term Care

* Office-Based Surgery

Under the hospital service line, JCAHO's Web site states that "The Joint Commission has been accrediting hospitals for more than 50 years. Its accreditation is a nationwide seal of approval that indicates a hospital meets high performance standards. Our accreditation helps hospitals improve their performance, raise the level of patient care, and demonstrate accountability in the rapidly changing health care marketplace."

Noticeably not included in the service lines are hospital-affiliated health and fitness centers, but rest assured if a team is surveying your hospital or ambulatory care facility, and you have a health and fitness center, be ready for an unexpected visit.

In preparation for this article, I corresponded with JCAHO Media Specialist Mark Forstneger, who said JCAHO does not and is not currently planning to accredit or certify hospital-affiliated health and fitness centers. However, don't let your guard down because surveyors have the right to visit any department of a hospital and look for the dreaded Type 1 violation that usually sends a hospital into a state of frenzy. Type 1 violations are defined as major violations of the JCAHO guidelines. They can vary from proper documentation of a patient's record to an unsafe condition in any hospital department.

For the purposes of a historical perspective on JCAHO, in 1910 Ernest Codman, M.D., proposed the "end result system of hospital standardization" as the guideline that should be used to measure the effectiveness of patient care. Under this system, a hospital would track every patient it treated long enough to determine whether the treatment was effective. If the treatment was not effective, the hospital would then attempt to determine why, so that similar cases could be treated successfully in the future. The formation of the actual Joint Commission occurred in 1951 when the American College of Physicians (ACP), the American Hospital Association (AHA), the American Medical Association (AMA), and the Canadian Medical Association (CMA) joined with the American College of Surgeons (ACS) to create the Joint Commission on Accreditation of Hospitals (JCAH), an independent, not-for-profit organization whose primary purpose was to provide voluntary accreditation for hospitals. In 1987, the organization changed its' name to JCAHO to reflect an expanded scope of responsibilities.

The mission of the JCAHO is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.

Generally, hospitals were scheduled at three-year intervals for accreditation. Normally, the dates were scheduled well in advance. Often, hospitals would hire surveyors to come and do what is known as a "mock" survey. These mock surveys would be done in advance of the actual scheduled JCAHO visit so that the hospital could "fix" any potential violations. That gave the hospital time to get ready for their JCAHO visit. Often, as soon as the survey was over, the hospital would take a breather and then start preparing for the next visit three years away. Many times, all the preparation that was done for the survey would go undone over the next three years, decreasing patient safety or hospital cleanliness; and then the cycle would start all over again with a mock survey in preparation for the triannual visit.

On January 1, 2006, JCAHO changed its' visit schedule and basically put all 15,000+ facilities that they survey "on notice" that a survey could occur unannounced at any time. The purpose was obvious; hospitals should be operating in the same, safe conditions everyday for patient safety and not just "fixing" problems for survey visits and final results. This is obviously a good approach to improve the daily delivery of care in health care organizations.

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So what do all of these have to do with a hospital-affiliated health and fitness center? Although these facilities are not listed on JCAHO's target lists, the surveyors have the right to visit any department of the hospital. It is typical for surveyors to visit physical therapy and cardiac rehabilitation within health and fitness centers. However, it is rare that a surveyor actually visits a stand-alone health and fitness center. However, if and when they do, you need to be prepared.

I interviewed some colleagues that have experienced visits from JCAHO surveyors over the past few years. The following are some accounts from each of the "lucky" facilities that have been visited:

David Standridge, the former director of Hurley Medical Center's Health and Fitness Center in Flint, MI, was visited twice during his tenure by JCAHO during their hospital visit. Standridge's health and fitness center was a multipurpose center with therapy, aquatics, and the usual compliments of fitness services. He told me that during the first JCAHO visit, the surveyor wanted to see their records for keeping Cholestec readings. Inasmuch as Cholestec machines come under laboratory JCAHO guidelines, the same scrutiny given to a full-blown hospital laboratory was given to the fitness center's area for measuring cholesterol by finger stick. They wanted to see the records of finger sticks taken, refrigerator and room temperatures, logs for test strips, and that no employee's lunch was being commingled with anything else in the laboratory refrigerator. During that visit, the surveyor actually gave the hospital a Type 1 violation because of their record keeping. The Type 1 violation was eventually removed after the problem was corrected.

On the second JCAHO visit, they went to the fitness facility again; but this time, they hurried through the center and were particularly intrigued by the aquatics center. Standridge said they seemed to want to ask questions about the hot tub and pool water temperatures, mechanical rooms, and record keeping, but didn't have time.

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This thought process was confirmed by Douglas A. Ribley, director of Wellness & Administrative Services for Akron General Health & Wellness Center in Akron, OH. He recently accounted, "we were surveyed about six months ago; and for the first time, the surveyor did more than just walk through our space and tell us how impressive our center was. Our surveyor walked into the aquatics area and asked to see the chemical logs. She then asked to see documentation on the credentials of our lifeguards. Fortunately, we had both and they were in good order. Our aquatics manager was well prepared and did a great job. The surveyor also asked to see the pump room and looked to see how chemicals are stored. The surveyor ended up spending about one hour in the fitness center portion of our building, which reduced the time she spent in diagnostics and outpatient surgery. The clinical areas (who prepare so hard for this visit) were stunned as well as our vice president, but this is how it went down. I have heard that similar experiences at other centers have occurred over the past year."

Jennifer K. Hopper is the manager at Piedmont Hospital Health & Fitness Club in Atlanta, GA. In speaking with Hopper, she said, "I have been in two JCAHO surveys. This year, we eagerly await our first unannounced survey."

Hopper explained that in the previous surveys, a meeting time was set aside for each division. The division vice president, a physician representative, director, and managers sat down with the surveyors. Hopper said, "We each were asked our affiliation with the division and how we assimilate with the hospital. After the meeting, the surveyors visited each department. The surveyors were interested not only in operations, but expiration dates on fire extinguishers, cleanliness, and what was done in the event of an emergency situation. The surveyors also were interested in our aquatic area and how we sanitized our pools."

"This year, we anticipate the surveyors to interact more with our employees," said Hopper. "This has given me the opportunity to empower my team to have confidence in their roles and how our programming complements departments throughout the hospital system."

Jane McBride, manager of HeartLife and Life Center Programs for Greenville Hospital Systems in Greenville, SC, just recently had JCAHO visit their hospital under the new unannounced survey policy. McBride reported that they were prepared but the surveyors did not visit their particular facility nor did they ask any questions or require any specific information on their programs.

As you can see, there are a variety of possibilities coming from a JCAHO review. The surveyors tend to visit more often, ask more questions, and look for standards that are often applied to clinical areas.

"For the fitness area, they are really looking at patient confidentiality and safety, that is, member files being locked when not in use, faxes and medical clearances coming into a private office and overall safety and documentation of policy and procedures," said Jinger Berry, executive director of the Health and Fitness Institute, which is part of Stamford Hospital in Stamford, CT.

"This year JCAHO will most likely will be looking at the Fitness Center again, I am not sure how closely; but since it is included in the Tully Health Center (a 225,000-sq ft outpatient facility), we are on our toes more than ever," Berry said. "We also have a Crusin to Compliance team that tours all departments of the hospital asking questions to prepare employees for surveyors."

Stamford Hospital provides each of its departments with the following checklists to ensure compliance with nonclinical issues related to facilities and staff:

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JCAHO Environmental Hazard Surveillance Checklist

Nonclinical Areas

* Check construction areas for safety compliance and infection control issues

* Storage

* Extraordinary storage in the hallway

* Equipment should be on one side of the hallway, remove equipment not being used

* Storage-All storage must be kept at least 18 inches below fire sprinkler heads.

* No storage on floor

* No "fixed" (without wheels) furniture in hallways

* Doors

* Doors are not propped open

* Stored items do not block doors

* Work Practice Observation

* No heavy objects are lifted over the chest level

* Proper lifting techniques are being used

* Confidentiality

* Medical records/patient names/status are secure when unattended

* Hazardous Materials

* The MSDS manual is accessible

* Chemicals are properly labeled

* Flammables are stored properly

* Chemicals in the areas are represented in the MSDS

* Check Housekeeping cart

* Electrical

* Extension cords are not in use

* All plug equipment have had an initial electrical safety inspection

* All equipment are tagged

* All equipment are grounded and double insulated

* Electrical cords are oriented not to be a trip hazard

* All electrical boxes and mechanical spaces are locked

* Life Safety

* Fire extinguishers are not blocked

* Fire extinguishers are mounted and labeled above

* Fire extinguishers have had the monthly inspection. (Make sure it's not more than 28 days since the last inspection)

* Pull stations are not blocked

* Storage is not within an 18-inch plane from the sprinkler head

* Exit signs are working properly (evenly illuminated)

* Exit signs are clearly visible

* Fire doors are not blocked in any way

* Hallway railings are free from obstructions (storage)

* Nothing blocking fire exits, fire pull boxes, or gas shutoffs

* No holiday decorations

* Emergency equipment

* Eyewash stations have been exercised every week (check log)

* Breaker panels are not obstructed (36-inch clearance)

* Housekeeping

* High and horizontal surfaces are cleaned

* Surfaces are clutter free and are properly cleaned

* Cleaning supplies are not left unattended. Cleaning supplies secured

* Housekeeping closet is locked

* All waiting areas should be clean and tidy-including bathrooms

* No housekeeping carts left unattended

* No broken or soiled ceiling tiles

* No holes in wall

* All doors close without forcing them

* No surge protectors plug into purge protectors

* No paper signs (flammable) on walls or doors

* Garbage removed and trash covered

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Staff Training

Review the following items with the staff:

* "RACE" (emergency rescue)

* "PASS" (fire extinguisher use)

* Job competencies (name three)

* Age-specific competencies (as appropriate to your staff)

* How to complete an incident report, Peminic (anyone can complete an online incident report)

* What the MSDS sheet is

* Where the MSDS sheets are located

* The content of an MSDS sheet

* Where the closest fire exit is

* Where the closest alarm box is

* Where the closest fire extinguisher is

* Explain the "Right to Know"

* What JCAHO stands for

* Explain HIPAA

* How to clean up a large blood spill

* How to explain "Blood-borne Pathogens" (as appropriate to your staff)

* How to describe what "PPE" is (as appropriate to your staff)

* What an internal and external disaster is

* What the Patient Rights & Responsibilities are

* Their role in a fire

* Review National Patient Safety Goals with staff and JCAHO Quick Reference Guide

So don't be afraid of JCAHO, just be prepared. If you follow their guidelines, suggested actions, training for staff, and general recommendations, you will be ready for any unannounced visit and you will be providing your members with a safer facility to have a great workout experience.

© 2006 American College of Sports Medicine


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