I get the dubious pleasure of escorting surveyors, doing presentations, etc
for all regulatory agencies from a state level on up. It's actually not that
bad. The surveyors I have met are not on a witch hunt or out to shut down
hospitals at the drop of a hat. If you get a bunch of type 1's, you usually
get a chance to correct the problem and then they will resurvey. They have a
website and you can email specific questions at www.jacho.org. They are
overseen by HIPPA who will survey 10% of the facilities that JACHO done
within a year as a governing/check and balance kind of thing.

As far a breastfeeding support goes, patient education is a very big deal.
They base what they look for on standards of care, usually obtained from
professional organizations (ILCA), evidence based guidelines etc. For us that
means complete documentation of multidiciplinary education (not just the LC
but staff nurse and MD's as well). Consent to treat is also a biggie-no more
bringing patients back in to the hospital for a quick look/helping session.

JCAHO has a soft cover book of standards that is probably located within the
department that interacts the most with the surveyors (Education, Risk
Management, Legal Counsel). Administraton will also have the standards as
well and will be happy to help you find answers-they are usually the ones
creating the nervous environment in the first place <g>.

Hope this helps!
Denise Altman, RN, IBCLC, LCCE
Columbia, SC

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