Joint Commission Surveys, Part 4 - Have a Plan

This article, “Have a Plan”, is the final installment in a four-part series on preparedness for a Joint Commission Survey. This article addresses being prepared for the details and activities that come with Survey Day. All four articles in the series can be accessed here.

Our last article covered performing Mock Tracers in your department and a Mock Survey at your facility. They are necessary precursors to a successful Joint Commission Survey. Today we address the realities of Survey Day and the preparations you should make.

Survey Day

You’ve just been informed that the Joint Commission Survey team has arrived in the lobby. Gulp.

A thousand questions run through your mind. Are we prepared? Did we forget to review the sterility checks in the Pharmacy Clean Rooms? Has anyone seen the Medical Director? What about all of those Environment of Care Standards – are we ready? Are Nursing’s competency assessments complete? Did the Laboratory get approval on the updates to their Quality Management Plan?

Relax. All of the worry in the world cannot change things at this point. Your vigilance and planning up to now should have done the job. Have a notebook, tablet or laptop with you and be ready to take notes as necessary.

Although you may know your inspection window, Joint Commission Surveys are always unannounced. Your organization should have a plan on what to do. Again, you have access to all of the resources you need for success¹.

Details, Details

Successfully completing a Joint Commission does depend to some extent on planning and calm leadership. TJC does have some excellent resources to help you plan. This Survey Activity Guide has great details on what to expect and how to prepare.² It has a department-by-department breakdown of what to expect, and even has a handy guide on what steps to take when the Survey team arrives.

You will no doubt have a list of key personnel to inform at the time of the Survey team’s arrival. If one key person cannot be reached, they should have a backup. Your organization will also have to validate the authenticity of the survey by logging in to the Joint Commission extranet site. You will also have the opportunity to download the Survey agenda.

As always, refreshments in the meeting room are a good idea.

You should expect something similar to the following events, although it depends upon the nature of the facility or programs accredited at your location:

• Surveyor Preliminary Planning Session

• Opening Conference

• Orientation to Your Organization

• Individual Tracer Activity

• Program-Specific Tracers

• Daily Briefing (if Survey lasts >1 day)

• Competence Assessment and Credentialing/Privileging

• Environment of Care and Emergency Management Session

• Facility Orientation – and Life Safety Code® Building Assessment

• System Tracers

• Regulatory Review (where applicable)

• Clinical Leadership and Staff Discussion

• Governance Discussion Session

• Leadership Session

• Medical Staff Credentialing and Privileging

• Surveyor Report Preparation

• CEO Exit Briefing

• Organization Exit Conference

Preparing with the elements of the Survey in mind, assign responsibility to each point in your survey agenda to the appropriate individuals or teams.

Conclusion

This series began by looking two opposing groups of emotions that a Joint Commission might elicit. The first was anxiety, worry, and downright fear. The second was excitement, accomplishment, and the satisfaction of a job well-done. Viewing the entire Survey and Accreditation process from this context is critical. The Survey process is not a sophisticated game of “gotcha”. The surveyors are providing a practical assessment of your organization’s patient care processes.

Surveys are meant to be educational in nature, not punitive. Surveyors have seen dozens, perhaps hundreds of organizations similar to yours, and may be able to recommend best practices that you will benefit from. Survey findings should be regarded an an opportunity to improve patient care.

Be prepared for some hard work during and after the Survey. We at StaffReady wish you the best, and hope that you find some excitement, accomplishment, and the satisfaction along the way.

Did this article series catch your eye? View all of StaffReady’s Blog articles here.

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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.

1. https://www.jointcommission.org/accreditation-and-certification/health-care-settings/hospital/

2. https://www.jointcommission.org/-/media/tjc/documents/accred-and-cert/survey-process-and-survey-activity-guide/2020-all-programs-organization-sag.pdf

^{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.}

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