article, “Past Performance”, is the second
in a four-part series on preparedness for a Joint Commission Survey.
This article addresses a review of your past Joint
Commission Surveys. Stay tuned to StaffReady’s
blog for future
last article introduced the reader to Surveys (inspections) performed
by The Joint Commission (TJC). Here we cover looking back at past
Surveys and actions taken. Once again, remain focused on facts and
leave your fear behind.
Once you’re comfortable with how the survey process works, it’s time to review your past Survey results. The Survey results, any deficiencies cited, plan(s) of correction, and proof of compliance should be housed in one place. Read through each section that pertains to your department or area of responsibility. The deficiencies noted will be classified as either a “Standard-level” or “Condition-level” deficiency.
Standard-level deficiencies are those where a standard was violated on an infrequent basis, perhaps just once. They do not indicate a threat to safety, but need to be corrected nonetheless.
Condition-level deficiencies are considered more serious, and likely pose a risk of harm to patients, staff, or visitors. Frequency of occurrence and how widespread the individual deficiencies are may also factor into a Condition-level deficiency. Deficiencies here will require a plan of correction and evidence of compliance. A follow up Survey at 60 days should have occurred.
Condition-level deficiencies require that a Plan of Correction (POC)
be filed and then approved by TJC. In
many cases, a POC will be required for Standard-level deficiencies as
well. Many organization chose to create a POC for each deficiency
even when not required by TJC, as it provides for a consistent
approach to performance improvement.
key to any successful POC is doing what you say your going to do.
Follow through is paramount. Assume
that every deficiency
from your last Survey
will be a topic of review during your upcoming
Survey. As you look
through prior Survey records, note what areas were cited and what
actions were promised in the POC(s) for each. Now you need to look
for proof. Treat it like an investigation and go out and look for
you can get a copy of the POCs for your organization, taking good
notes will be crucial.
Note the Standard or Condition cited, the nature of the deficiency,
and the specifics of the POC. Assuming there was a follow up survey
or a records review of some sort, take note of the specific records
reviewed as evidence of compliance. Repeat this for each deficiency
in your department.
may think that you can pass by some items on your list – resist
that temptation! Forcing yourself to go and look up the records in
question will take some time. That time is well-spent if you
discover a flaw in how your POC has been executed. When Survey
comes, you will have the assurance that your plan is working – or
that there was a problem and you took steps to correct the issue.
note on automation
the POC may have included automation as the answer. Let’s use
temperature records as an example. If the citation was for
inconsistent recording of temperature in
controlled spaces, such
as a freezer, does the automated system record the temperature as
designed? Can you see the records? Are any days or times missing?
Were new freezers purchased...and are they monitored with the same
solution? Automation can fail and people will forget - and relying
blindly upon either is sure to lead to a citation.
deficiencies may be far more complex than our simple example above.
They are also often
one of these issues in your department, you may have to refer to
other resources if the results of the POC are not obvious. It’s
one thing to check to see if a new fire door was installed at a
and quite another to determine whether or not required modifications
were made to the HVAC system servicing
for the Next Step
your review of past Surveys and POCs is complete and your are
confident in your compliance in those areas, it is time to broaden
your view. Our next article in this series, “Self Survey”, will
delve into the processes of Mock Surveys and your own self-survey of
your department. It will be time to become skeptical, hard-nosed,
and thick-skinned. Sometimes the truth hurts.
Have a thought on this topic? Comment on LinkedIn
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, time TBD. Click here to register. Use JCRStaffReadyJan2021 as the key when registering.
1 https://www.psqh.com/news/once-again-safety-issues-top-list-of-most-cited-tjc-standards/, accessed 11/06/2020
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.