article, “Self-Survey”, is the third
in a four-part series on preparedness for a Joint Commission Survey.
This article addresses the process of performing a mock
Survey on your own department or facility. Stay
tuned to StaffReady’s blog
for the final installment.
we mentioned in the last article, it is time to become skeptical,
hard-nosed, and thick-skinned.
You and your fellow leaders are armed with the Joint Commission Standards, previous Survey findings, Plans of Correction and Evidence of Compliance. You know where to start.
It is now time to turn your attention to your own facility or department, and view it as if you had never seen it before. Observe with a critical eye.
No Fear – but sometimes the truth hurts.
viewing your department or facility as an “outsider”, take the
same path as a Surveyor would. If you usually come in through the employee
entrance, come in through the front door. First impressions mean a
lot. Is the lobby clean, organized, and well lit? Is the signage
clear? Would a Surveyor know how to find each department? Even in a
small facility, this may not be obvious to the individual who
is naive to your
you walk, take in your surroundings. A fire extinguisher – what’s
the inspection or fill date? Does that stain on the ceiling look
like a water leak? Would that bit of frayed carpet be considered a
tripping hazard? These might be fairly minor issues, but can create
a bad impression.
As you approach the outpatient registration area, is there any PHI exposed? Are registration conversations given at least a modicum of privacy? Are orders and other paper records kept out of view? The temptation with any observations you make is to make excuses:
“Yes, well, we really can’t do that because...”
“This is our process – it’s how we do things.”
“Changing this is out of question – it’s too expensive.”
careful with that last excuse. Joint Commission standards are
standards of excellence.
They are the standards your organization aspires to and needs to
meet for accreditation. Excusing a solution away as “too
expensive” is lazy. Look at problems with fresh eyes. More on
The Joint Commission (TJC) has used the Tracer Methodology as a means of assessing compliance and outcomes since 2004. One example Tracer activity might go as follows:
“Show me three MRI results (or pharmacy dispensing records or laboratory results or…) from August 2019.”
“OK, let’s take a look at Jennifer Hernandez’s record here. I want to see the original order, any preliminary results, the maintenance records for that MR imager, the credentials and license for the technologist who ran the test and for the Radiologist who did the interpretation.”
of those requests, once fulfilled, can easily lead to other
questions. The Survey team can quickly gain a sense of the
safety and consistency of care across departmental lines within your
organization. So – time to do your own Tracers.
patient records coming from your department (adhering to all your
organization’s rules regrading access to patient records, of
course). Look at every touch point that leads to that record
on that patient on that
day – perhaps specimen collection, quality control, temperature and
humidity records, competency assessments on staff, quality assurance
activities, and more. The records should all be retrievable and
displayable to a Surveyor.
you cannot produce these
sorts of records or are missing some vital steps in the process of
operating your department, prepare for deficiencies on Survey day!
You may have time, however, to recover “lost” records – stored
in the wrong folder in the document imaging system, in a binder filed
in the wrong location, or
even records in the basement that were moved by housekeeping. In
the worst case – records that
lost – document this
using your organization’s quality assurance process.
Self-discovery of an issue (and the steps taken to prevent its
recurrence) are far better than a surprise on Survey day.
far the best practice is to carry out Mock Surveys within your
organization. If you are a part of a larger healthcare system,
organizing teams from one facility to survey your facility are
particularly effective. There are numerous online resources for such
an undertaking. TJC has
excellent content on their websites.1,
it’s time to thicken your skin.
have been humbled by this process; apparently my “perfect”
department left a bit to be desired in a couple of areas. Once the
bruises to my ego healed, we were able to improve and standardize
processes between facilities. We
uncovered areas that needed attention, and developed internal best
practices from other areas. All
in all, we improved our departments, and created a better environment
for success and patient
Mock Survey is quite an undertaking, involving representatives from
every department and service line in your organization. It is
usually sponsored by your Quality Management or
Regulatory Compliance, or similar team. It takes a substantial
amount of planning, and should be treated as seriously as an actual
Survey. A closing
conference should be held, and leadership attendance should be
Ready for the Last Steps
and your organization have done quite a bit of work to get to this
point. You have validated processes in your departments, uncovered
and corrected problems. Hopefully, you have learned from one another
to improve the quality of care in your institution. Our last article
in this series, “Have
a Plan”, speaks to
keys points to remember when Survey Day arrives.
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Interested in learning more about 2021 Joint Commission Surveys? Join us as we sponsor a Joint Commission webinar entitled “Your Joint Commission survey during the COVID-19 Pandemic: What has changed?” on January 13, 2021, 10:00 am PST, 1:00 EST. Click here to register.
This program on January 13, 2021 will award 1.0 Continuing Education contact hour for the following: ANCC, ACCME, ACHE, ACPE, & CJCP.
Full attendance at every session and completion of a post-engagement survey are prerequisites for receiving full continuing education credits.
In support of improving patient care, this activity has been planned and implemented by StaffReady, Inc. and Joint Commission Resources. Joint Commission Resources is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
The Joint Commission is authorized to award the listed hours of pre-approved ACHE Qualified Education credit for this program toward advancement or recertification in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants should log into their MyACHE account and select ACHE Qualified Education Credit.