Help! The Joint Commission's on Their Way: How to Prepare

Help! The Joint Commission's on Their Way:
How to Prepare

By Kathleen Catalano, RN, JD

This article:

  • Provides a step-by-step process to prepare for the Joint Commission's visit.
  • Lists four broad steps to take and several specific actions that can assist in organizing preparation efforts.

You just received the dates of the upcoming triennial survey. It is not that you were unaware that the Joint Commission on Accreditation of Healthcare Organizations was paying a visit, but now the date is set and almost here. How do you prepare?

First of all, pull out the Joint Commission Survey Report from the last triennial survey and, if applicable, unannounced survey. Next, find the reports of any other regulatory agency from which the facility may have received a deficiency. Review these and make certain that all Type I and supplemental recommendations have been addressed and that other noncompliances have been corrected.

Secondly, "walk through" the Comprehensive Manual for Hospitals (CAMH) to find out whether there are any new standards of which you were not aware. For example, as of January 1, 2000, standards TX.8, regarding resuscitation, and LD.1.10, dealing with clinical practice guidelines, became effective. Also of note is the fact that the pain management standards that become effective January 1, 2001 are already in the CAMH. (Pain management standards can be found in six chapters of the CAMH. Those chapters are Patient Rights and Organization Ethics, Assessment of the Patient, Care of the Patient, Education, Continuum of Care, and Improving Organization Performance).

It is important to recognize that the Joint Commission surveyors will be less consultative during future surveys than they have been in the past. The surveyors will truly survey the facility with the message of the standard and the intent of each standard in mind. Be aware of the fact that the surveyors can now issue multiple Type I recommendations for one deficiency. Leadership, a pervasive chapter, may be the vehicle through which a facility receives a "double-bang." For example, a facility may have received a recommendation during their last survey. If the deficiency is not corrected, the surveyors could conceivably give a recommendation for noncompliance with the standard and another under leadership for not making sure the problem was corrected.

The third step toward preparation is to review and revise all policies, procedures, and protocols that the Joint Commission has requested to be included in the Document Review Session. Remember that the surveyors will review documents on the survey's first day. After reviewing the documents and meeting with the organization's leadership, the surveyors split up and begin visiting various departments and services at which time the surveyors will question staff and survey the facility according to what is written in the documents.

Discrepancies between policy and practice will certainly be spotted by the surveyors. The surveyors compare notes at the end of each survey day. At that time, they share their experiences and advise each other what to watch for during the remainder of the survey. The surveyors will base their decisions on what is written in the facility's policies, procedures, and protocols. With that in mind, if you discover that practice varies from policy, procedure, or protocol, change the policy unless it is based on a prescriptive Joint Commission standard. For example, the Joint Commission states that the History and Physical must be on the medical record within 24 hours of admission for an inpatient. This is a prescriptive standard.

It is interesting to note that very few Joint Commission standards are actually prescriptive. Many institutions receive Type I recommendations, not because the Joint Commission standard was too prescriptive but because the institution was not compliant with its own policies, procedures and protocols, or the Medical Staff Bylaws and Rules and Regulations.

Another important thing to remember is that the strictest standard (i.e. Joint Commission, facility-specific, state, or federal) will be applied by the Joint Commission surveyors. Thus, for example, if the Medical Staff Bylaws have a requirement that all verbal and telephone orders must be authenticated within 24 hours, the surveyors will hold the physicians to that time frame. At that point, it does not matter that neither the state nor the Joint Commission has such a requirement. Just for the record, the Joint Commission only requires medical staff members to authenticate four types of records: the History and Physical, consultations, operative reports, and discharge summaries.

Step four regards the environment of care Statement of Conditions (SOC). Has the SOC been updated to include present buildings, environment, and planned additions and modifications? Has the facility adopted the Joint Commission's Building Maintenance Program (BPM)? The BPM is a preventive maintenance program that can be adopted by any facility. Several items are included in the preventive maintenance program (fire door closures, exit signs, fire wall penetrations, etc.), and if during the actual survey 95% of the items function properly, no Type I recommendation will be issued if and when an item fails to function properly.

These four steps provide a fairly good snap shot of where a facility is in its survey preparation efforts. If, after review, you find areas that are noncompliant and realize that they all cannot be brought into compliance, decide which areas can be "fixed" adequately in the time before survey. You'll have to leave the rest to chance. There's a point at which you can truly do no more.

What if you have completed all of the above four steps and there's still time remaining? In that case, continue to peel back the layers of the onion. What else needs to be done? Why not begin with the staff? It is always amazing just how little staff remember from one survey to another. All the coaching done three years ago was for naught because staff do not seem to remember most of the information. However, staff have a great deal on their plates taking care of patients. Additionally, some staff members feel that any survey process is leadership's problem, and they do not want to be bothered with the details. It is imperative that leadership connect preparation for surveys to quality patient care. Staff should understand that the reason the organization puts all the policies, procedures, and protocols in place is to assist them in rendering better patient care.

Education and staff involvement are the keys to success. If there's time, pick a theme for the survey process, and make it fun for the staff to be involved. Consider having senior leadership walk the units and departments asking the staff questions. If staff answer the questions correctly, they receive an inexpensive prize. All kinds of things can be done to make this preparation process entertaining yet meaningful. Just like with performance improvement, it is great to maintain the gain, so it should be emphasized that changes made for the survey will be continued after the survey is over. It is best to remain prepared. One can never know who may be walking though the door next.

As for education, it is tricky. Do not start too early because staff will not remember the information for the survey or they may peak before it's showtime. Education is also something that cannot be boring, so instructors should not use the same teaching techniques every time. The teaching method must be innovative and give staff a reason to remember what is being taught.

One method to determine how ready open and closed medical records are for survey is to review a number of both open and closed medical records (50-200) randomly, depending on the organization's size. A group of three to four individuals should review these medical records for content. Medical records, nursing, and the medical staff should be represented. Those chosen for this review should not be managers or directors. Use the Joint Commission's, "Surveyor Medical Record Review Tool for Open and Closed Records," which can be found on the Joint Commission's Web site at for this purpose. Enhance the tool with additions or deletions pertinent to the organization. Then have the group review the random sampling of records, tally-up the results, and see where weaknesses exist. At that point, decide which areas can be remedied within the time remaining before the survey and/or which battles you are willing to take on.

An issue that will be addressed during every survey will be that of sentinel events. Each organization should have a sentinel event policy in place outlining the role and responsibilities of both staff and leadership in the event that a sentinel event occurs. Surveyors may ask to see the root cause analysis, resulting action plan, and any monitoring performed following an actual sentinel event. If possible, avoid disclosing to the surveyors the documentation for a true sentinel event unless the sentinel event has been reported to the Joint Commission or, in the event of a lawsuit, the case is already settled. It would be advantageous to explain to the surveyors that yes, you have had a sentinel event, but the legal department has said that due to discoverability issues, you cannot show them the documentation for a true sentinel event. Instead, show them the work that has been performed on a "near miss" or on an event that was noted while benchmarking with other organizations. This solution does two things. First, it lets the surveyors know that the organization follows the Joint Commission's policy on sentinel events and performs root cause analyses, resulting action plans, and monitoring of sentinel events. Secondly, that the organization is proactive and has practiced root cause analyses on incidents other than true sentinel events.

Performance improvement (PI) is another area of concern for most organizations. Almost everyone has a written PI plan, which designs or redesigns processes and monitors the heck out of things. What most organizations fail to do is aggregate and analyze the data they collect. This will be a major focus during the survey. The following questions must be answered:

  • Where does all the data that is collected go?
  • Is the data aggregated and analyzed?
  • Does everyone know how to use the PI tools such as control charts, pareto diagrams, run charts, histograms, etc.?
  • Are staff using the PI tools when presenting their PI projects to the various committees to whom they report and is the information documented in the committee minutes?
  • Are staff continuing to improve processes even after they have been "fixed"?
  • Is the organization using the ORYX data that has been collected?

Infection control must be addressed as well. Each service and department must be prepared to explain to the surveyors what they do to prevent nosocomial infections. Staff should also be able to explain whether or not reusable sterile items are time-related or event-related. In any area of the facility where instruments are cleaned and sterilized, there will be questions that relate to the uniform performance of care. For example, if most endoscopes are cleaned using a STERIS® machine, are any cases done using scopes that have been cleaned in Cidex®?

Other issues that continue to plague infection control practitioners are toy cleaning, flash sterilization, negative airflow rooms, tuberculosis, treatment for resistant organisms, and reports to the health department. In almost every survey, the minutes of the Infection Control Committee are reviewed. Questions will then stem from those minutes. Thus, be familiar with the minutes, and be prepared to discuss any actions taken and the results.

It is never easy to prepare for a Joint Commission survey. You must remain alert and view the surroundings with "outside eyes." Walk the units, services, and departments as an outside observer. Be vigilant and question practices to which everyone may have become accustomed but that do not seem right. Are medications controlled? Are there open medical records on the counter at the nurse's station for everyone to see? Does the staff document patient/family education? Ask yourself whether the facility will ever truly be prepared for the survey. If the answer is maybe, the organization is pretty much ready for the games to begin. Now, smile, take a deep breath, and greet the surveyors as they arrive at the front door.

Kathleen Catalano, RN, JD, is a senior consultant for The Greeley Company in the areas of Joint Commission accreditation, performance improvement, risk management, patient care services, medical staff, medical records, medical/legal issues, and compliance.

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