They can be stressful but are also helpful in prioritizing areas of improvement.
Dear Director,
It feels like forever since we have had a Joint Commission survey. What are they focusing on now?
Let’s start with the basics. The Joint Commission (TJC) is an independent, not for profit organization that accredits health care organizations. You may know TJC as JCAHO, or “Jaycoe,” but like Dunkin, they’ve gone through some rebranding.
Hospitals “voluntarily” pursue accreditation and I put quotes around voluntarily, because without accreditation, you cannot get Centers for Medicare & Medicaid Services (CMS) funding. CMS controls Medicare and Medicaid, which are critical to hospital reimbursement. Although there are some alternatives to the TJC survey, which occurs every three years, 90% of hospitals contract with TJC to achieve accreditation.
The surveys themselves focus on patient safety and quality. The surveyors use a matrix called the Survey Analysis for Evaluating Risk (SAFER). The Y axis is “likelihood to harm a patient/staff/visitor ranging from low to high and the X axis is the scope, ranging from limited to widespread throughout the organization.
All findings need to be addressed within 60 days, but high risk and widespread issues (such as restraints being used throughout the hospital without required documentation and evidence of necessity or blocked fire exits that could pose a life safety risk) can result in follow up visits.
Site Visits
Having a Joint Commission survey is almost like having an open book test. They are generally not at your hospital to make new rules for you. However, they are there to ensure that you are complying with regulatory regulations, following your hospital policies and providing safe, high-quality care to your patients.
TJC, like everyone else, put things on hold when the pandemic began. They delayed their routine surveys and have been playing catch up for some time. If your hospital contracts with TJC for surveys, they generally come every three years to conduct a full survey. Depending on the hospital size, this could take a few days to a week or more. While your regularly scheduled triannual survey may be delayed a few months, ultimately, TJC will arrive for their unannounced survey at your hospital.
The inspection team typically consists of at least one physician and one nurse. These are the people you may directly interact with. If you’re a department leader, you may meet surveyors during a tour of your department when you’ll be asked both clinical and operational questions related to life safety (i.e., where are your oxygen shut off values or the location of your fire extinguishers?).
I have generally found that while surveyors will select nurses who are working clinically to interview, I don’t typically see them select the physicians. But, if you are asked to speak with them, just speak to how your hospital operates, answer confidently and only answer the actual question, and know that part of the answer can always include reaching out to your medical or nursing leadership team or accessing your hospital intranet for resources.
The survey includes a focus on what TJC calls “life safety and environment of care.” That portion of the survey focuses on ventilation, temperature management, OSHA regulations, fire and smoke barriers, emergency management, and hazardous materials and storage. While they may walk through the Emergency Department for that portion, the surveyors will generally not be looking for physician staff, but they’re still surveyors so be on your best behavior (food, drinks, patient interactions, etc.)
On the physician side, you can expect charts related to high-risk procedures to be reviewed to include blood transfusions, procedural sedation, restraints and EMTALA transfers. You will hear the term “tracers” which means TJC survey team will review a large number of charts during their inspection. From there, if they identify a concerning issue, they will continue to “trace” the charts to determine if the issue is a limited finding or one that may be widespread and requires more organizational focus.
The initial chart reviews are typically active patients. That means the documentation that occurs on patients leading up to the survey and while the surveyors are there are fair game for review. (Thus, it is more important than ever to complete charts in a timely fashion.) When the surveyors identify a potential safety issue and they *will* find a potential safety issue, they may do a deeper dive into that type of patient (specific procedures, transfers, pediatric patients, etc.) and look through older records. They may also “trace” a patient from entry into the facility through discharge to review our continuity of care, hand-off and overall patient movement through the facility from diet orders to discharge orders.
When it comes to consents and procedures, the basics have not changed. Fully complete the consent form as you have always been taught. While it sounds simple, if you review these cases regularly, you know you will come across incomplete consent forms or cases where you can’t find the consent (was it not done or was it just not scanned into the record?).
Here’s the basics: Include laterality if it is appropriate. For instance, a procedure titled “reduction of dislocated shoulder” should be “reduction of RIGHT dislocated shoulder.” Always, have the patient (or their representative) sign consent. Have a witness sign consent. And don’t forget to sign your name. Make sure dates and times are completed.
This sounds so simple, yet it is amazing to me how frequently we find a missing signature (sometimes from the doc, sometimes from a nurse witness) and more often a missing time or date. Building good habits with this routine documentation will reduce stress down the line and ensure compliance with hospital policy. Documenting a timeout prior to the procedure with the care team along with site marking, should also be routine. This procedure is routine for surgeons in the operating room, but probably less hardwired for us in the emergency department.
About 20% of my patients require a translator. Sometimes registration will document Spanish as a preferred language even when the patient is fluent in English and happy to speak English. In patients who do not speak English, certified translator use with identifying info (ID at least) needs to be documented on every interaction and/or their needs to be a note that a translator was offered but the patient did not want it and chose to speak English (or chose to have a family member translate, etc.). Follow your hospital policy. Some hospitals do not allow family to be the translator for medical procedures.
TJC will always review your institution’s restraint cases and your policy. Some tips I have learned throughout my career include the following: know your policy, document to that policy, make sure restraints are used as a last resort for the safety of the patient and/or staff, document a detailed face-to-face assessment, and partner with nursing to ensure that restraints are removed as quickly as possible to provide a least restrictive environment.
PRN medications often used in the ED setting for agitation, psychosis or aggressive behavior are appropriate, but documentation of patient condition should support the use and if using the term “chemical restraint,” you should ensure that your hospital policy supports this use and you know the documentation required, which is typically the same documentation required for physical restraints.
Also be sure nursing is aligned with you, so everyone is properly documenting at the correct intervals based on the order and hospital policy. Did I mention hospital policy? The most important part of any regulatory visit is making sure you aren’t violating your own policies. This is how many organizations end up with requirements for improvement (RFI) – the surveyors will note that the organization is not adhering to its policies. To improve policy compliance, create dot phrases and/or order sets in your electronic medical record that outline the policy and prompt the provider.
Surveyors also closely examine patient falls and handling of critical lab values. Falls with injury are one of the most causes of sentinel events (it is encouraged but not mandatory that hospitals report sentinel events to TJC). Patient falls are usually more an inpatient issue but can happen in the emergency department. Critical value reporting is required to be verbal. Critical values are determined by the lab and usually approved by the Medical Executive Committee. There’s a reason you’re called about an elevated troponin, low sodium, or positive blood culture and asked to give your name.
New This Cycle
One of the more recent hot topics is hypertensive management of pregnant and postpartum patients. TJC is trying to positively impact maternal safety, and surveys since January 2021 have included a focus on maternal hemorrhage and hypertension.
At my facility, it’s very unusual to see a third trimester patient in the emergency department and postpartum patients with blood pressure issues also go to Labor & Delivery (L&D) quickly for evaluation.
However, as emergency physicians, we should be aware of the six “elements of performance” around hypertension in pregnancy and preeclampsia. Maybe a link to more information? It’s not within the scope of this review to detail each of them but each hospital should review the elements of performance, have appropriate policies in place, and provide annual education to both providers and nurses. OB/L&D should also undergo similar education.
There are a variety of examples that may provide this education, including online modules, discussion/education at staff meetings or even via an email. And yes, TJC will ask for proof that you have provided this education.
After widely publicized hospital shootings earlier this year in Tulsa, Oklahoma and Dayton, Ohio, it was particularly timely that TJC went live July 1 with new recommendations and elements of performance related to Emergency Management.
Emergency Preparedness is defined as “a continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective active in an effort to ensure effective coordination during incident response” (National Incident Management System-NIMS). The phases include preparedness, response, recovery and mitigation. This is the time to show your plan, how you coordinate with EMS and Police, and evidence of drills based on your hazard vulnerability assessment (HVA).
Finally, it may not be a surprise to hear that TJC is very focused on pandemic issues such as handwashing, mask wearing and personal protective equipment (gowns need to be tied in the back).
Conclusion
At this point in my career, I have been through countless Joint Commission surveys. They are always disruptive to your work week and stressful because the surveyors will find something that needs improvement or may have been overlooked. Sometimes it’s like pulling on a thread for them. And sometimes, pulling on that thread will lead to the unraveling of something you did not anticipate.
As a medical director, most of the time during the survey, I find myself waiting and being available in case there is a question or issue. I participate as invited, which is usually for about an hour during a meeting or a tour. Like during a deposition from an opposing attorney, keeping answers short and to the point may help prevent a new topic from being investigated. Be kind and courteous to the surveyors – they will often point out great things the facility is doing as well, which they call “leading practices.”
If you are performing quality review and improvement projects on the high-risk topics and providing regular feedback to your group, so people know the right thing to do, and are typically doing it, you can be confident that you’ll have a successful survey.
2 Comments
Full disclosure, I came across this article recently and texted it to my nursing admin partner. The Joint Commission showed up the next day. Call it bad mojo. I couldn’t find a way to work it into the column and I don’t think it will win you any points with the surveyors if you bring it up, but it’s kind of an interesting read.
https://pubmed.ncbi.nlm.nih.gov/35738660/
I am a regulatory specialist who deals with TJC surveys and appreciated your article. Loved the advice to just answer the question, be kind and courteous! Too many times I’ve seen the survey go off kilter because someone thinks this is the opportunity to dump on surveyors’ “blah blah blah” about why the Joint Commission is whatever.
The relationship is a delicate balance between your survey liaison or regulatory person, administration and the surveyors. You always want to be friendly, kind and helpful…..it goes along way towards a more successful survey.