Since the 1970s, the California Medical Association’s Institute for Medical Quality (IMQ) has participated in hospital licensure and accreditation surveys in partnership with The Joint Commission (TJC) and the California Department of Public Health under the Consolidated Accreditation and Licensure Survey Program. Although the program is no longer consolidated, hospitals that are surveyed by TJC can choose to have an IMQ physician surveyor replace one TJC surveyor on the team.

Since October 2014, approximately 50 percent of the hospitals scheduled for a survey in California have opted to have an IMQ surveyor participate in the survey. These hospitals have overwhelmingly indicated that the experience has been a positive one. Some comments received from hospitals on the evaluation forms state:

• “Great advice on all topics. In-depth knowledge of best practices.”
• “Having a practicing physician from CA who is familiar with CA regulatory requirements is very beneficial. As a practicing physician, the surveyor knows challenges facing physician practice and is able to discuss best practices implemented at other facilities.”
• “It was very collaborative so would suggest the same approach continue to be taken.”
• “Very knowledgeable of the survey process. Clear communication. Very approachable. Interacted well with staff.”

IMQ’s physician surveyors are experienced, actively practicing medical staff leaders, trained both in TJC standards and knowledgeable about state requirements and California practice. Choosing IMQ also means that the survey will include a medical staff leadership conference to motivate medical staff members to participate more fully in hospitals’ patient safety processes.

Any hospital preparing for a survey in the next 18 months can still choose to have an IMQ surveyor participate in their hospital survey. The steps to include an IMQ surveyor are:

• In your hospital’s electronic application, go to Tab 3 – Federal/State Tab.
• In the navigation pane on the left, you will find “Hospital – State of California.” You may or may not need to scroll down to find the Hospital section, depending on the services your hospital offers.
• Under “Hospital, State of California,” you can find the box for IMQ Participation, with the question:
• “I wish to request that an IMQ physician surveyor participate in my Hospital’s accreditation survey – Yes or No.”
• There is an attestation statement asking you to read the information, attest your understanding, and that you authorize the Joint Commission to include an IMQ surveyor by checking the box.

Be sure to save your changes when prompted. For more information, see the IMQ website.

Contact: Leslie Anne Iacopi, (415) 882-5167 or liacopi@imq.org.