Pop quiz at Tufts Medical Center

A Boston hospital is in the middle of a mid-week surprise.

Surveyors from the national accrediting organization known as the Joint Commission showed up at Tufts Medical Center on Wednesday morning to begin their five-day study of about 250 measures of quality and safety.

Hospital inspections used to be anything but unexpected. Until 2000, even "random unannounced surveys" came with advance notice. Now hospitals have to be on their toes for 12 months, anticipating visits that come every three years.

"Typically they come on a Monday, so to show up on Wednesday, we were a little bit surprised," Dr. David Fairchild, the hospital's chief medical officer, said in a phone interview this morning, day 5 of the visit. "Their mantra is, 'We can come any time.' Our strategy is to be ready no matter what day they come. They could come back next week."

This is Fairchild's first Joint Commission visit as chief medical officer, although he's seen them before at Tufts and at other institutions. More than the timing and secrecy of the inspections has changed, he said.

"It used to be, you knew they were coming, so you would save up things and do them at the last minute," he said. "It used to be cramming for the test. That's not a great strategy for improving system and quality in hospitals."

Before he came to Tufts, he said, he saw hospitals move copiers and stretchers out of hallways for the Joint Commission visit, and then move the equipment right back when the inspectors were gone. Widespread criticism halted the advance-notice policy in 2006.

"You basically pass the test, but don't improve the safety of your hospital in the long run" under the old model, he said. "I do think the Joint Commission has done a good thing by making hospitals think about changing the way they do business every day."

Today he is escorting a physician surveyor, one of four from the commission, around the hospital. Among other methods, surveyors measure hospital performance by tracing a patient's path through the hospital, say from the emergency room to the operating room to the intensive care unit. Surveyors check to see whether doctors and nurses have washed their hands or taken time-outs to be certain the right thing is being done for the right patient, Fairchild said. Charts are reviewed to be sure the medications are correct. Sometimes surveyors look only at patient records, other times they come to the bedside.

That's a change from past inspections that emphasized hospital policies and processes over how care was delivered.

"I give [the commission] credit for focusing more on national safety goals and things that are more relevant to improving the quality of care," he said. "Overall as a physician I feel much better about the things the Joint Commission looks at now as compared to, say, a decade ago."

Despite knowing for a year the review could come any day -- even a Wednesday -- everyone is a little bit nervous but proud, Fairchild said. Nurses and physicians come up to the surveyors and introduce themselves.

"It's been an incredibly exciting four and now five days," he said.

Then he had to go meet the surveyors.