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Guide to a Successful Joint Commission Survey

A Customer’s Guide to a Successful Joint Commission Survey:
Ideas to help you prepare for your accreditation visit.

 

Being surveyed by The Joint Commission  requires a tremendous investment of resources. As a customer of the The Joint Commission, you have rights and responsibilities in this process. In order to maximize your success, you must be an informed advocate for your organization.

 

From practical experience, members of the National Association of Psychiatric Health Systems (NAPHS) from across the country have shared their ideas for ensuring an efficient and cost-effective survey. This is intended to be a constantly evolving document. Please call us to add your thoughts.

 

Getting Started – Early Planning

  • Identify one spokesperson within your organization to be the consistent contact with The Joint Commission regarding scheduling, changes, concerns, etc.
  • Distribute scoring guidelines and updates to all staff. Know the standards!
  • Review recent editions of The Joint Commission Perspectives for changes.
  • Call other facilities that are comparable to yours that have recently been surveyed and ask questions such as, "What could have been done differently on the agenda to save time and make the survey more useful? What was the surveyor emphasis?"
  • Review Public Notification requirements. These are very specific and failure to comply with these requirements can result in a Type I recommendation.
  • If you had a sentinel event, be prepared to present your root cause analysis to the surveyors.
  • The surveyors have received a copy of your last triennial survey. Review your previous recommendations, making certain they all remain corrected in order to avoid any second generation findings.

 

The Application Process

  • Make sure you give clear and accurate information on the survey application. Do not hesitate to add additional clarifying information even if there is not a place (line or space) for it (e.g., chemical dependency (CD) services are only a tract; while the inpatient census has been high over the past 2 years, the census for the last 6 months has been significantly lower and is projected to remain that way because of the closing of inpatient beds; inpatient CD treatment is for detox only—all other CD care is partial-hospitalization or intensive outpatient, etc.). The information you give on the initial application drives all other decisions. If there are additions, deletions, or changes in your programs between the time of survey application and the survey, be sure to discuss these with your liaison.
  • You have the option of including a detailed cover letter with the application which clarifies your unique situation and needs (e.g., although licensed for 110 beds, the average daily census has not been over 50 for the past 12 months; the partial hospitalization program is blended, etc.)
  • You may request a specific surveyor or team. If you are assigned someone you do not want, you can contact The Joint Commission and request that another surveyor be assigned.
  • When setting up a tailored survey, negotiate for surveyors prepared to survey both AMH and BHC standards. When this is absolutely not achievable, insist that the surveyors be scheduled at the same time to eliminate duplication and over-surveying. In this case, make sure you receive both agendas prior to the start of the survey. Make sure the agendas are not duplicative or time will be wasted. You only need one leadership conference, building tour, etc. Do not assume that the AMH and BHC staffs at The Joint Commission have communicated about your survey. Coordinate the survey schedule yourself, in conjunction with the team leader, if you must.
  • The liaison is only a scheduling person and usually does not have direct experience working in a health care organization. Do not assume that he/she understands your structure or the relationship between your patient volume and the amount of survey time or number of surveyors required. One surveyor (ideally, the AMH surveyor) can often cover several different tailored functions. If you are unable to negotiate changes in the agenda with the liaison, use the survey team leader to arrange the schedule. The surveyor will have a better understanding of your needs. Keep working up the chain of command at The Joint Commission if you are not getting the help you need. NAPHS may be able to help you make the appropriate contacts.
  • If you are having trouble reaching your liaison (e.g., after the second unreturned phone call) ask for the survey scheduling department supervisor.
  • Be sure you understand the pricing structure from the very beginning. Carefully check the survey invoice for accuracy. Make sure you are being charged for the right number of days, number of surveyors, and patient volume. Also, make sure you are receiving the appropriate fee caps as they apply to your facility. The invoicing system can be very confusing. Do not hesitate to ask questions of the Joint Commission billing department.
  • Be sure the Statement of Conditions (SOC) is current. Do not overlook the completion of Part 4-Plan for Improvement (see Perspectives, Sept/Oct 1996). If something requires a JCAHO waiver, get it prior to the survey and attach it to the SOC.

Getting Close to the Survey

When you receive the first draft of the survey agenda:

  • Make sure you are not scheduled for services you do not have.
  • Make sure pertinent services have not been left off the agenda.
  • Check the time allotted for survey of each component. If the time seems excessive for the services you have, address this ahead of time with the survey team leader.
  • Insist on receiving a final agenda at least one week prior to survey to allow time to schedule your staff.
  • Remember—the schedule is negotiable depending on patient needs, availability of staff, and geography of service areas.

You may call the survey team leader prior to the survey and ask questions to clarify survey procedures and to know "what to expect." Surveyors all have voice mailboxes which can be accessed through the JCAHO switchboard.

 

Keep the agenda concise and tightly scheduled. Work to have the right number of surveyors for the right amount of time to increase efficiency and decrease cost. Inquire about blocks of time during which nothing is scheduled. "Consultation and teaching" time are your options—you may decide to use or not to use this service.

 

Clarify ahead of time with the survey team leader which off-site service locations will be visited. Make sure travel time to and from the location is discussed as part of the scheduling process.

 

Clarify with the survey team leader which sessions a medical staff member is expected to attend to allow time for the M.D.s to arrange their schedules.

 

Discuss scheduling of the Medical Records review with the team leader. It can be on either the first or second day. There are advantages and disadvantages to each. In small facilities, request that the Performance Improvement team interviews be conducted together if your team members overlap from one team to another.

 

On short surveys (two surveyors for two days), some team leaders have been willing to provide organizations with an initial list, prior to survey, of the medical records and credential and human resource files they may want to have available for review. This is always subject to change or addition on site. If you have not received this list ahead of time, be sure to ask for it during the opening conference.

 

The On-Site Visit

  • Present only the documents for review that have been requested in the presurvey package. Have these well-organized and labeled. Present all information with a positive attitude.
  • Ask during the opening conference if The Joint Commission has received any complaints that need to be investigated. Clarify what the procedure will be.
  • If any questions, problems, or conflicts develop during the course of the survey that cannot be satisfactorily resolved, ask the team leader to call The Joint Commission with you for clarification.