Planning for a JCAH survey

Abstract

A pharmacy department's planning and preparation for a JCAH survey are described, and advice on meeting JCAH standards is presented. Problems resulting from expansion of pharmacy programs and staff at the hospital were analyzed, and a plan was developed to correct inconsistent procedures and inadequate documentation. JCAH source materials were studied to gain understanding of the standards and their application in this institution. A manager was appointed to carry out the plan, and the pharmacy staff was directly involved in planning for the survey. Priorities for corrective action were set on the basis of previous recommendations, current JCAH emphasis, and effect of the problem on patient care. Checklists were used to evaluate progress toward correcting deficiencies. Documentation of pharmacy operations was organized and summarized for presentation to the surveyor. A mock survey was conducted to assess preparation of the staff and physical aspects of the pharmacy. The pharmacy's goal was to meet all JCAH standards. The systematic preparation, the quality assurance procedures, and the training of the staff provided a basis for achieving this goal and maintaining high standards of operation.