Medical Library Association | Resources : Librarian's Guide to a JCAHO Accreditation Survey

Resources

Information Management Resources for
Hospital Accreditation

A resource for MLA members who are preparing for accreditation in clinical and educational health care settings

Accreditation Organizations
Accreditation Advice
Discussion Lists
Library Standards
Workshops
Other Resources

Accreditation Organizations

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
JCAHO Department of Standards answers questions about standards and compliance, 630.792.5000
Accreditation Council for Graduate Medical Education
American Osteopathic Association Hospital (AOA)
Canadian Council on Health Services Accreditation (CCHSA)
(previously the Canadian Council on Health Facilities Accreditation)
Liaison Committee on Medical Education
Association of American Medical Colleges (AAMC) and the Council on Medical Education of the American Medical Association (AMA)
State medical societies are accredited by the ACCME and, in turn, accredit intrastate sponsors of continuing medical education. The Hospital Libraries Section Standards Committee is currently (winter 2002/2003) promoting the "Standards for Hospital Libraries 2002" to all state medical societies. A copy of the standards is being sent, along with a copy of "Raising the Bar: the Importance of Hospital Library Standards in the Continuing Medical Education Accreditation Process" and a cover letter encouraging them to incorporate the 2002 standards into their CME accreditation process. Contact Jeannine Cyr Gluck for further information.

Accreditation Advice

The MLA Liaison to the JCAHO, Katherine R. Stemmer Frumento, AHIP, can answer questions concerning JCAHO information management (and other pertinent) standards and is participating in a revision of the JCAHO's information mangement standards.
JCAHO surveyors
- JCAHO itself will send biographical sketches of the surveyors scheduled to visit you and tell you the last three sites visited by each surveyor; call JCAHO at 708.916.5600 and ask for the Department of Accreditation Operations
- also search MEDLINE and CINAHL to see if surveyors have published or have been the subject of articles
- discussion lists (see below)

Discussion Lists

The following discussion lists cover issues related to the JCAHO standards and accreditation process. To subscribe to these lists, send an email with the body of the message being subscribe [listname] to the respective address given below:

JCAHO-WATCH is a discussion list intended for hospital staff directly involved in accreditation to communicate with colleagues. It is especially useful for learning how other hospitals handle specific issues.
A query to MEDLIB-L about a surveyor will likely result in a response from someone recently surveyed. Respondents usually feel more comfortable responding to you personally, rather than to the list. More general questions about accreditation issues or other topics appropriate to health sciences librarianship are welcome.
CANMEDLIB-L

Workshops

The Joint Commission Standards: Information Management and Beyond
Instructors: Susan Long, Janet Cowen (current course accreditation expires May 30, 2003); 4 MLA contact hours
MLA CE offerings change; check the Educational Clearinghouse for the current roster.
Role of the Library in Accreditation (Videotape)
A 90-minute VHS videotape of MLA's first satellite teleconference. this program provides an overview of the accreditation process presented in three parts: 1. Preparing for the Accreditation Survey; 2. The Day of the Survey—Highlighting Your Library's Role in Your Institution; and 3. Using Survey Results—Promoting Your Library within Your Institution. Examples used are from JCAHO, LCME, CCHSA and other accrediting bodies. Includes Participant's Manual and CE credit. Contact MLA's Professional Development Department for more information.

Library Standards

MLA's "Standards for Hospital Libraries 2002"
FAQ's for the "Standards for Hospital Libraries 2002"
Standards for Library and Information Services in Canadian Healthcare Facilities, 2nd edition
Canadian Health Libraries Association/Association des bibliothèques de la santé du Canada (CHLA/ABSC) Task Force on Standards for Library and Information Services in Canadian Healthcare Facilities, Toronto, ON, Canada. CHLA/ABSC, 1995. Order from CHLA/ABSC.
ACGME standards include requirements for health sciences libraries.

Other Resources

Joint Commission Resources (JCR)
JCR is the source for books, journals, and accreditation manuals of JCAHO. Includes journals Joint Commission Perspectives, Joint Commission Perspectives on Patient Safety, Environment of Care News, Joint Commission Benchmark, and Joint Commission Journal on Quality and Safety.
Change, Librarians, and JCAHO
January 1994, by Neil Rambo
Competencies for Hospital Librarians. Stanley, EH. National Network 2000 Apr;24(4):12-3,20.
"Competencies for Special Librarians of the 21st Century" from the Special Libraries Association.
DocKit #10: Accreditation and the Hospital Library: Information Management Plans and Assessment Tools
The JCAHO Comprehensive Accreditation Manual for Hospitals includes guidelines for obtaining, managing, and using information to improve patient outcomes and individual and hospital performance in patient care, governance management, and support process. DocKit #10 provides examples of information management (IM) plans, institutional responses to IM plans, and assessment tools.
Compiled by Kay E. Wellik, AHIP; Mary J. Jarvis, AHIP; and Connie Schardt, AHIP. MLA, 1997. (Currently out of print; may be available via ILL)
Getting Ready for the Visit: JCAHO Accreditation
October 1996, from Inside Information, Health Sciences Library, University of Virgina.
Going beyond information management: using the Comprehensive Accreditation Manual for Hospitals to promote knowledge-based information services. Schardt CM.; Bull Med Libr Assoc 1998 Oct;86(4):504-7.
IAIMS and JCAHO: implications for hospital librarians. Doyle JD. Bull Med Libr Assoc 1999 Oct;87(4):383-6.
A Librarian's Guide to a JCAHO Accreditation Survey
The purpose of this guide is to provide answers to questions that librarians might have about the JCAHO accreditation process as it relates to libraries and information services.
Librarian's Survival Kit
This resource kit was developed by the MLA Task Force on the Role of the Librarian and headquarters staff to help promote the value of a health sciences librarian and the services provided to an institution.
Order from MLA: Item #5320. $18.00 ($30.00)
"Proactive roles for librarians in the JCAHO accreditation process" Rand DC, Gluck JC. Journal of Hospital Librarianship 2001;1(1):25-40.
Raising the bar: the importance of hospital library standards in the continuing medical education accreditation process. Gluck JC, Hassig R. Bull Med Libr Assoc 2001 Jul;89(3):272-6.
The Role of Knowledge-Based Information
1994, by Christiane Jones, Terrie Wheeler, and Wendy Carter
Tip Sheet on Needs Assessments for Health Sciences Libraries
1994, by Nancy Press.

Revised January 2003 by Jeannine Gluck.