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

August 1, 2000

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

First of all, pull out the Joint Commission Survey Report from the last triennialsurvey and, if applicable, unannounced survey. Next, find the reports of any otherregulatory agency from which the facility may have received a deficiency. Review these andmake certain that all Type I and supplemental recommendations have been addressed and thatother 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 withclinical practice guidelines, became effective. Also of note is the fact that the painmanagement standards that become effective January 1, 2001 are already in the CAMH. (Painmanagement standards can be found in six chapters of the CAMH. Those chapters are PatientRights 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 lessconsultative during future surveys than they have been in the past. The surveyors willtruly survey the facility with the message of the standard and the intent of each standardin mind. Be aware of the fact that the surveyors can now issue multiple Type Irecommendations for one deficiency. Leadership, a pervasive chapter, may be the vehiclethrough which a facility receives a "double-bang." For example, a facility mayhave received a recommendation during their last survey. If the deficiency is notcorrected, the surveyors could conceivably give a recommendation for noncompliance withthe 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, andprotocols that the Joint Commission has requested to be included in the Document ReviewSession. Remember that the surveyors will review documents on the survey's first day.After reviewing the documents and meeting with the organization's leadership, thesurveyors split up and begin visiting various departments and services at which time thesurveyors will question staff and survey the facility according to what is written in thedocuments.

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 theirexperiences 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 frompolicy, procedure, or protocol, change the policy unless it is based on a prescriptiveJoint Commission standard. For example, the Joint Commission states that the History andPhysical must be on the medical record within 24 hours of admission for an inpatient. Thisis a prescriptive standard.

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

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

Step four regards the environment of care Statement of Conditions (SOC). Has the SOCbeen updated to include present buildings, environment, and planned additions andmodifications? Has the facility adopted the Joint Commission's Building MaintenanceProgram (BPM)? The BPM is a preventive maintenance program that can be adopted by anyfacility. Several items are included in the preventive maintenance program (fire doorclosures, 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 anitem fails to function properly.

These four steps provide a fairly good snap shot of where a facility is in its surveypreparation efforts. If, after review, you find areas that are noncompliant and realizethat 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 tochance. 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 timeremaining? In that case, continue to peel back the layers of the onion. What else needs tobe done? Why not begin with the staff? It is always amazing just how little staff rememberfrom one survey to another. All the coaching done three years ago was for naught becausestaff do not seem to remember most of the information. However, staff have a great deal ontheir plates taking care of patients. Additionally, some staff members feel that anysurvey process is leadership's problem, and they do not want to be bothered with thedetails. It is imperative that leadership connect preparation for surveys to qualitypatient care. Staff should understand that the reason the organization puts all thepolicies, procedures, and protocols in place is to assist them in rendering better patientcare.

Education and staff involvement are the keys to success. If there's time, pick a themefor the survey process, and make it fun for the staff to be involved. Consider havingsenior leadership walk the units and departments asking the staff questions. If staffanswer the questions correctly, they receive an inexpensive prize. All kinds of things canbe done to make this preparation process entertaining yet meaningful. Just like withperformance improvement, it is great to maintain the gain, so it should be emphasized thatchanges made for the survey will be continued after the survey is over. It is best toremain 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 rememberthe information for the survey or they may peak before it's showtime. Education is alsosomething that cannot be boring, so instructors should not use the same teachingtechniques every time. The teaching method must be innovative and give staff a reason toremember what is being taught.

One method to determine how ready open and closed medical records are for survey is toreview a number of both open and closed medical records (50-200) randomly, depending onthe organization's size. A group of three to four individuals should review these medicalrecords for content. Medical records, nursing, and the medical staff should berepresented. Those chosen for this review should not be managers or directors. Use theJoint Commission's, "Surveyor Medical Record Review Tool for Open and ClosedRecords," which can be found on the Joint Commission's Web site at www.jcaho.org forthis 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 seewhere weaknesses exist. At that point, decide which areas can be remedied within the timeremaining 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 andresponsibilities 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 anymonitoring performed following an actual sentinel event. If possible, avoid disclosing tothe surveyors the documentation for a true sentinel event unless the sentinel event hasbeen reported to the Joint Commission or, in the event of a lawsuit, the case is alreadysettled. It would be advantageous to explain to the surveyors that yes, you have had asentinel event, but the legal department has said that due to discoverability issues, youcannot show them the documentation for a true sentinel event. Instead, show them the workthat has been performed on a "near miss" or on an event that was noted whilebenchmarking with other organizations. This solution does two things. First, it lets thesurveyors know that the organization follows the Joint Commission's policy on sentinelevents and performs root cause analyses, resulting action plans, and monitoring ofsentinel events. Secondly, that the organization is proactive and has practiced root causeanalyses on incidents other than true sentinel events.

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

  • 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 beprepared to explain to the surveyors what they do to prevent nosocomial infections. Staffshould also be able to explain whether or not reusable sterile items are time-related orevent-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, ifmost endoscopes are cleaned using a STERIS® machine, are any cases done using scopes thathave been cleaned in Cidex®?

Other issues that continue to plague infection control practitioners are toy cleaning,flash sterilization, negative airflow rooms, tuberculosis, treatment for resistantorganisms, and reports to the health department. In almost every survey, the minutes ofthe 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 theresults.

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

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



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