THE CALS SURVEY IS CHANGING -- KNOW YOUR OPTIONS

by Melvin Britton, MD, FACP, MACR, Chair, IMQ Board of Directors and
Ron Bangasser, MD, President, California Medical Assoc.

The Consolidated Accreditation and Licensure Survey (CALS) has undergone major changes over the past year. Beginning in 2004, California acute care hospitals will have two options for being surveyed. Hospitals will be asked to select one option prior to their survey date. This letter is meant to clarify the options that will be offered.

The first option is to continue with the singular CALS in which the California Department of Health Services (DHS), the Institute for Medical Quality (IMQ) and the Joint Commission for Accrediting Healthcare Organizations (JCAHO) jointly survey a hospital for both accreditation and licensure. The second option is to undergo an accreditation survey conducted either by JCAHO or the American Osteopathic Association (AOA), in addition to an unannounced licensure survey conducted by DHS and IMQ.

For hospitals choosing the first option, the CALS survey will be significantly different from previous years. It will use the JCAHO's new tracer methodology to conduct the survey. In addition, IMQ will send one surveyor to participate on the first and second days of the survey, rather than send several surveyors on the final day of the survey as it had done traditionally. IMQ, JCAHO and DHS have revised their survey protocols to reduce redundancies and improve coordination. This new integrated survey will be pilot tested the first week of January. IMQ surveyors participating in the CALS survey will be trained by JCAHO directly to assure consistency in the survey methodology.

Hospitals selecting the second option will undergo two separate surveys. The first will be an accreditation survey exclusively from JCAHO using the new tracer methodology. The second will be a separate, unannounced licensure survey from DHS and IMQ that will use traditional survey methodology. By law, DHS must conduct these licensure surveys at least every two years. DHS and IMQ are prepared to begin these unannounced surveys in January.

It is anticipated that the CALS survey will continue to involve a more consultative approach, whereas the licensure surveys will be more evaluative. If the new CALS process is successful, the second option may be eliminated mid-year and CALS reestablished as JCAHO's only survey option in California.

If you have any questions or would like further information about the new survey options and processes, please contact IMQ at (415) 882-5151. Thank you.