S p o n s o r e d b y

5 Essential Tips to a Successful Joint Commission Survey

TABLE OF CONTENTS

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INTRODUCTION: KEEP CALM AND SURVEY ON Page 03

TIP ONE: YOU CATCH MORE FLIES WITH HONEY Page 04

TIP TwO: ILLUMINATE WITH YOUR P & Ps Page 05

TIP THREE: DON’T REPEAT THE PAST Page 06

TIP FOUR: FOCUS ON TODAY Page 07

TIP FIVE: PRACTICE BEING SAFER Page 08

ABOUT POLICYSTAT: PASSIONATE FROM THE START Page 10

PLEASE NOTE: This guide is intended for informational purposes only and is not meant to replace legal advice. The information contained within is based on current information as of November 2016. PolicyStat received no compensation for creating this content and is not affiliated with, nor do we endorse any particular brand mentioned in the guide.

Preparing for a Joint Commission survey can be a monumental task that no healthcare

organization finds relaxing, but the rewards of accreditation are worth the effort.

Being an accredited healthcare organization gives you a competitive edge because

Joint Commission accredited organizations are recognized for giving better quality of care, attracting a better quality of staff and

reducing risks.

In this guide, we suggest five essential tips to a successful Joint Commission

survey.

Keep Calm and Survey On

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TIP ONE: YOU CATCH MORE FLIES WITH HONEY.

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As a healthcare organization seeking or maintaining accreditation, you are dedicated to continuous improvement and the best possible patient care. And, not coincidentally, The Joint Commission’s mission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission is on your side, so be as helpful as possible.

1 Put your best foot forward. Because surveyors mostly arrive unannounced, make sure your front desk staff is pleasant and attentive to everyone. On the day of your survey, the surveyor arrives around 7:45-7:50 a.m. unless your organization opens at a later time, so make sure you are kicking off each morning with a happy staff.

Designate a knowledgeable staff member as the data contact. The survey will progress much quicker if you are able to easily retrieve and print the requested documentation.

Create a “base” station with all the essentials. At the minimum, prepare a well-lit, designated area with a desk/table and chair, electrical outlets, phone and internet access for the surveyor.

Be careful with your words. If you don’t know an answer, don’t make one up. Instead, indicate that you know where you can find the answer. Be concise and avoid using unsure language such as, I think we, we’re supposed to, and on my shift we. Don’t argue with surveyors even if you think they are wrong.

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TIP TwO: ILLUMINATE WITH YOUR P & Ps.

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Joint Commission Standards and regulations should be followed as a matter of standard operating procedure. Use your knowledge of applicable standards when reviewing your policies and procedures to make sure your processes incorporate standards requirements.

1 Don’t simply copy and paste. The Joint Commission Standards may include some information that is not relevant to your organization, so make sure you only include the parts that apply to you in your policies and procedures. Additionally, be sure to word your P & Ps as simply and plainly as possible to make them easy to understand.

Be realistic. Organizations are often cited for not following their own policies and procedures. Instead of coming up with what you think is an “ideal” process, find out how all processes are implemented in the healthcare setting so that your P & Ps match what goes on in reality.

Be consistent with the format. Staff members should not only be able to easily locate the policy, but they need to know what section of the document contains the information they need. This may be as simple as dividing each document into labelled sections such as Policy, Purpose, Persons Affected, Responsibilities, Procedures and Definitions.

Make them easy to find. Use a searchable policy and procedure management software for easy access. Look for policy management software with automated periodic review reminders, approval routing, integrated collaboration, electronic signatures and powerful reporting to help you keep policies up to date and to help you maintain compliance.

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TIP THREE: DON’T REPEAT THE PAST.

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Each year, the Joint Commission reports on the most frequent compliance standard issues, and often, the same problems appear on the list from one year to the next. Dig up your last one or two audits to ensure your organization has maintained corrective actions from previous citations.

1 Determine previous compliance issues. what risks or threats were involved?

Identify the scope of compliance. who is affected by the standard ?

Determine how compliance was met after the citation. what procedures and controls were put in place to minimize the risk to patients, visitors and staff?

Audit your current compliance. Are the procedures and controls still being followed? Could they be improved?

Perform a root cause analysis and determine a course of action for negative findings. Devise and implement a corrective plan, and recheck compliance.

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Illustrated below, the PDSA cycle is a scientific quality improvement method used for action-oriented learning. Test your improvements by planning, implementing the plan, observing the results and acting on what is learned.

Plan StudyDo Act

TIP FOUR: FOCUS ON TODAY.

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Instead of trying to cram for a survey, focus on daily continuous improvement. Spending an extra five minutes ensuring standards are met today can save days of time spent correcting errors later. Give your staff tools to help them check their own standards knowledge and compliance.

1 Gently remind staff. To help your staff memorize key standards information, use visual cues and place them on staff badges, post them in hallways and behind desks, and make certain that your staff understands and can provide examples of how the organization meets the Joint Commission standards. NOTE: be sure that postings are controlled and meet the requirements of all your accrediting agencies.

Do daily housekeeping. Encourage good habits by implementing a daily checklist of common survey items. Start with the Joint Commission’s Continual Survey Readiness document and create one that is specific to your organization.

Communicate in several manners. People learn in different ways. Provide a number of communications to help staff work on standards. Some ideas include a weekly newsletter, a daily email or instant message, and games. For example, to help her staff with survey-readiness, Kelly D. Young, MD, MS developed a fun, interactive PowerPoint based on the game show, Jeopardy! The game addresses information that is helpful to have memorized in the event of a survey.

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© Joint Commission Resources, Inc. May be adapted for internal use. 1

Continual Survey Readiness: Daily Clean Sweep

To be performed by the unit/department director, supervisor, or other designee. Check ( ) when items meet expectations.

Unit/Department: ____________ Clean Sweep Dates: ____________________

Items to Check Mon Tues Wed Thurs Fri Sat Sun Crash Cart

Daily checklist completed No clutter on top Locked No expired supplies noted

Clean Holding Room Oxygen tanks upright, in holder, full and empty tanks separated

with signage Top of linen cart covered when not in use; solid bottom on cart Door to hall closed

Refrigerator/Freezer Temperature checks completed; response to variances recorded Open insulin vials dated Discharged patient medications managed according to policy

Point of Care Glucose Meters Cleaned per policy Controls and strips dated per policy when opened

Medication Carts/Storage Areas No open single-use vials; discarded after use Multi-dose vials dated MAR/eMAR closed when not in use Pill crushers and splitters cleaned per policy All doors/drawers locked when not in use per policy time frames

Housekeeping and Security Trash contained Drawers locked, as appropriate per policy

TIP FIVE: PRACTICE BEING SAFER.

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The Joint Commission has eliminated the A and C categories of their scoring methodology in favor of the Survey Analysis for Evaluating Risk (SAFER) matrix*. The new method plots the degree of likelihood to harm a patient, visitor or staff along with the range of its scope. The purpose of the SAFER scoring method is to more accurately depict the significance of compliance issues and make it easier for organizations to prioritize their areas needing improvement. Practice using the new matrix with mock tracers to acclimate yourself to the new method.

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HIGH

MODERATE“A colonoscope used for the operating room was stored in

an operating room cabinet with the tip of the colonoscope

touching supplies stored in the bottom of the cabinet.”

“During an upper endoscopy procedure, a GI technician entered

the endoscopy suite from the adjoining endoscope reprocessing room in order to place a processed

endoscope into storage. This practice posed an unacceptable risk of cross-contamination. During an

endoscopy procedure, the GI technician opened the endoscope

storage closet to retrieve a CLOtest kit. This action had the potential to expose the stored endoscopes to

aerosolized particles in the endoscopy suite.”

“During a building tour of the Imaging/Radiology Center and the

Emergency Department, it was observed that, in all of the

respiratory carts inspected, the oral airways were stored in bulk and not individually wrapped,

thereby creating the possibility for cross-contamination.”

LOWIn the supply room was one opened and partially used

bottle of 0.9% normal saline used for dental irrigation. The bottle was not labeled with the open date, and the instructions

on the bottle stated 'discard unused portion'.

“During the building tour in the pediatric area, the intake room

and two examination rooms were observed. Located under

the sinks in all three areas were multiple boxes of gloves at risk

of damage from water.”

“During the building tour it was noted that in the radiology area there were several cardboard

boxes on the floor that appeared to be water logged.

In addition, throughout this entire facility there were other

cardboard boxes stored directly on the floor at risk for water

damage.”

LIMITED PATTERN WIDESPREAD

IC.02.02.01 - The hospital implements infection prevention and control activities when doing the following:IC.02.02.01, EP 4 - Storing medical equipment, devices, and supplies.

Scope

1 Plot your observations. Start with an applicable standard. Observe the environment, staff and patients, and plot all noncompliance issues on the SAFER matrix. Then, repeat the process with the next standard.

*Effective June 2016 for deemed psychiatric hospital surveys. Takes effect January 2017 for all other surveys.

See the Joint Commission’s slide deck on the SAFER matrix for detailed information on survey and post-survey implications.

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HIGH MM.03.01.01, EP8 MM.03.01.01, EP7

MODERATEMS.01.01.01, EP5PC.01.02.01, EP4PC.01.02.03, EP6PC.01.03.01, EP1PC.01.03.01, EP5

IM.02.02.01, EP3MS.08.01.01. EP1MS.08.01.03, EP3

IC.02.01.01, EP2IC.02.02.01, EP4

LOW RC.01.01.01, EP19RC.02.03.07, EP4

LIMITED PATTERN WIDESPREAD

2 Plot the standards where compliance issues arose. Take all the standards where you found problems and place them on the matrix in all applicable areas.

Analyze the results. Looking at the grid, look for trends that apply to the same standards. Chances are that you can find even more noncompliance issues relating to these standards.

Take action. Prioritize your noncompliance areas in order of the highest risk, most widespread down to the lowest risk, limited scope. Refer to the chart on the right; you should tackle the red sections first. Then move from there to the darker orange, the lighter yellow-orange and bright yellow.

Document everything. Keeping the records of these efforts will show surveyors that you are working hard to meet compliance standards.

There is scarcely a perfect survey, but the Joint Commission is not expecting that. Let them provide guidance for you, and your patients, staff and organization will reap the benefits.

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SAFER Matrix™ Placement

Required Follow-Up Activity

HIGH/LIMITED,

HIGH/PATTERN,

HIGH/WIDESPREAD

• 60 day Evidence of Standards Compliance (ESC)- ESC will include Who, What, When, and How sections

• ESC will also include two additional areas surrounding Leadership Involvement and Preventive Analysis

• Finding will be highlighted for potential review by surveyors on subsequent onsite surveys up to and including the next full triennial survey

MODERATE / PATTERN,

MODERATE/WIDESPREAD

• 60 day Evidence of Standards Compliance (ESC)- ESC will include Who, What, When, and How sections

• ESC will also include two additional areas surrounding Leadership Involvement and Preventive Analysis

• Finding will be highlighted for potential review by surveyors on subsequent onsite surveys up to and including the next full triennial survey

MODERATE / LIMITED,

LOW / PATTERN,

LOW / WIDESPREAD

• 60 day Evidence of Standards Compliance (ESC)- ESC will include Who, What, When, and How sections

LOW/LIMITED

• 60 day Evidence of Standards Compliance (ESC)- ESC will include Who, What, When, and How sections

Prioritized Follow-up Action

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Priority

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