MARCH 2011THE JOINT COMMISSION SURVEY

PROCESS OVERVIEW

San Antonio APIC

AGENDA

TJC Survey Process (hospitals)TJC Chapter RequirementsPeriodic Performance Review (PPR)Survey ReadinessInfection Control & Prevention Chapter

ResourcesDiscussion & Questions

OBJECTIVES

Provide an overview of TJC Survey Process (hospitals)

Review the TJC Chapter Requirements & Infection Control & Prevention Chapter

Discuss Periodic Performance Review (PPR) & Survey Readiness

Share TJC Survey Related Resources

TJC SURVEY PROCESS

Unannounced Survey Process Posted on TJC secure extranet site by 7:30 a.m.

Survey window – 18 to 39 months after previous full survey

Strategic Surveillance System (S3- past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self reported sentinel events), data from an organization’s electronic application, and HCAHPS data.

TJC Survey Team Composition (based on size & complexity of your organization) -> Lead Surveyor, Administrator, Nurse, Generalist, Specialist (e.g. lab), Life Safety Code Specialist

TJC SURVEY PROCESS

Opening Session (Leadership)– survey overview & orientation to organization

Document Review – Policies, Plans, Meeting Minutes, CensusIndividual Tracer Activity– Isolation Patient, Surgical PatientSystem Tracers – depends on the size/complexity of your

organization Infection Control & Prevention Medication Management Data Use

Program Specific Tracers – suicide prevention, patient flow, lab integration

Competency & Medical Staff Credentialing & Privileging

TJC SURVEY PROCESS

Infection Control & Prevention System Tracer Composition of Team (IC members -> Employee Health,

Pharmacy, Lab, EVS, Facilities Management, Nursing, Procedure Areas)

Scheduled after Document Review & Individual Tracers Discussion - review of accomplishments and opportunities

Exit Briefing & Exit Summary - “Summary of Survey Findings Report” Direct Impact Standards Condition of Participation Deficiencies -> Central Office

Review Indirect Impact Standards

Infection Control & Prevention System Tracer

IP Program Assessment & PlanPopulation Demographics Annual PlanMDROs -> Lab (culture result tracking), Pharmacy,

Dietary, EVS, NPSG, trackingSSIs -> Health Optimization Prior to Elective Surgery,

types of procedures monitored, Joint, Cardiac and Bariatric Surgery

Device Related Infections -> CLABSI, VAP, CAUTIReview of a patient in isolation as a table top tracer

Type of isolation Education of staff, patient, visitors Tracking & Notification

TJC SURVEY PROCESS

Potential Accreditation Decision – “Accreditation Survey Findings Report” posted on secure extranet site includes the potential accreditation decision (within 2 days usually)

Central Office Review – COP, Immediate Threat, Situational Decision Rules

Final Accreditation Decision – Evidence Standards Compliance (ESC) Immediate Threat to Health or Safety Situational Decision Rules Direct Impact Standards (45 days) Indirect Impact Standards (65 days) MOS – 4 months

Continuum of survey activity outcomes

Reports that meet a decision rule that automatically triggers a PDA, Cont or AFS or a report with a CMS Condition level or APR deficiency will be reviewed by TJC Central Office. Reminder: CMS conducting validation surveys

TJC CHAPTER REQUIREMENTS

Chapter – NPSG, EC, EM, HR, IC, LD, MS,PI,TSStandard (Requirement) – statements that define

the performance expectations and/or structures or processes

Rational – background, justification, additional information

Element of Performance (EP) – identify performance expectations

References – help to identify related standards/EPs

Icons

TJC CHAPTER REQUIREMENTS

Numbering Requirements Standard six digit number broken down into three

sets of two numbers each For Example, IC.02.04.01

First two letters are the chapter acronym First two digits refer to the Roman numeral in the outline Second two digits refer to the letter under the Roman

numeral in the outline Last two digits refer to the standard number

Chapter Roman Numeral

Letter in Outline

Standard Number

IC 02 04 01

Infection Prevention and Control

II (section – Implementation)

D 01

TJC CHAPTER OUTLINE - IC

I. Planning A. Responsibility (IC.01.01.01) B. Resources (IC. 01.02.01) C. Risks (IC.01.03.01) D. Goals (IC. 01.04.01) E. Activities (IC. 01.05.01) F. Influx (IC. 01.06.01)

II. Implementation A. Activities (IC.02.01.01) B. Medical Equipment, Devices, and Supplies (IC.02.02.01) C. Transmission of Infection (IC. 02.04.01)

III. Evaluation and Implementation (IC. 03.01.01)

TJC Glossary of Terms

EP

Element of Performance

M Measure of Success required

DWritten Documentation required

2/3EP Criticality Tag: 2=Situational Decisional Rule; 3=Direct Impact

A/CScoring Category: A=Y/N; C=3 strikes out

EP Scoring Scale

0 Insufficient Compliance

1 Partial Compliance

2 Satisfactory Compliance

High

Low

What is the immediacy of risk to the patient?

What is the time line for resolution of non-compliant findings?

Short

Long

Example – Scoring and Icons

Documentation

Criticality Tag 3 MOS

Scoring Scale

Scoring Category

TJC Periodic Performance Review

Tool for self-assessing compliance with standards and requirements between on-site surveys

Process to identify potential areas of concern, and opportunities to make ongoing adjustments.

PERIODIC PERFORMANCE REVIEW

Organization’s self assessment with chapters, standards and EPs

Noncompliant Standard – Plan of Action(POA); Measure of Success (MOS)

Completed annually one year after survey

Several Options for submission Full PPR and 3 other options

PERIODIC PERFORMANCE REVIEW

Review using

resources

Questions: Contact Facility

Administrator

TJC Survey Readiness

PPR – self assessment & POAs/MOSMock Individual/Patient, Progam Tracers – IP

and TeamInfection Prevention & Control related examples

Isolation Patient Tracers – MDRO’s, Precautions Surgical Patient Instrument handling and reprocessing Biohazard Waste Food and Nutrition Services Environment of Care

Practice Infection Control System Tracer

TJC Survey Readiness

Infection Control & Prevention Chapter Summary - Planning

IC.01.01.01 – Identifies individual(s) responsible for program

IC.01.02.01 – Leaders allocate needed resources for program

IC.01.03.01 – Hospital identifies risks for acquiring and transmitting infections

IC. 01.04.01 – Based upon risks hospital sets goals to minimize possibility of transmitting infection

IC. 01.05.01 – Hospital has an IP and Control PlanIC. 01.06.01 – Hospital prepares to respond to an

influx of potentially infectious patients

Infection Control & Prevention Chapter Summary - Implementation

IC.02.01.01 – Hospital implements its IP and Control program

IC.02.02.01 – Hospital reduces the risk of infections associated with medical equipment, devices, and supplies

IC.02.03.01 – Hospital works to prevent transmission among patients, LIPs and staff

IC. 02.04.01 – Hospital offers vaccination against influenza to LIPs and staff

Infection Control & Prevention Chapter Summary – Evaluation &

Improvement

IC.03.01.01 – Hospital evaluates the effectiveness of its IP and Control Plan

National Patient Safety Goals

Goal 7 – Reduce the risk of health-care associated infectionsMeeting Hand Hygiene GuidelinesPreventing MDRO’sPreventing CLABSIPreventing SSI2012 – VAPs and CAUTI

Sentinel Events – separate chapter

2010 Challenging Standards - IC

Identify risks for acquiring/transmitting infection. IC.01.02.01/EP#1&2 (Identify & prioritize risks based on location, community, and services provided)

Reduce the risk of infections associated with medical equipment, devices, supplies. • IC.02.02.01/EPs #1,#2, #4 (Implement infection prevention and control activities when cleaning, performing disinfection, sterilizing, and storing) {DIRECT IMPACT}

Resources Available

JCR & TJC Publications – Perspectives

Infection Prevention & Control Publications

TJC Hospital E-dition 2011 (updated July and before January)

TJC website (www.jointcommission.org/Standards/FAQs) BoosterPak R3 Report TJC Leading Practice Library

Joint Commission Center for Transforming Healthcare (www.centerfortransforminghealthcare.org/)

IP Networking

TJC BoosterPak(As of January 2011 two BoosterPaks Published)

Full version

available on HITT

site.

R3 Report (As of January 2011 One Report Published)

Leading Practice Library

Leading Practice Library