Joint Commission Surveys, Part 2 - Past Performance

This 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 installments.

Our 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.

Plans of Correction

All 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.

They 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 the evidence.

Sleuthing

Unless 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.

You 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.

A note on automation

Sometimes 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.

Continuing to Dig

Other deficiencies may be far more complex than our simple example above. They are also often organization-wide issues.¹ When reviewing 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 specific location, and quite another to determine whether or not required modifications were made to the HVAC system servicing your department.

Ready for the Next Step

Once 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.

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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, 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.}

Photo Credits: racorn and Andriy Popov