12 simple steps to Joint Commission survey success

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Constant readiness for a Joint Commission survey may never be easy or perfected, but there are steps you can take to make preparing for it less stressful, said Kurt Patton, MS, RPh, principal of Patton Healthcare Consulting in Glendale, AZ, and Pat Pejakovich, RN, BSN, MPA, CPHQ, a consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

During the recent inaugural Association for Healthcare Accreditation Professionals Conference in Las Vegas, the two experts offered 12 essential ways that accreditation coordinators can make this process easier.

The 12 suggestions, varying in topic and difficulty, are as follows:

1. Learn more about Environment of Care (EOC) and the Life Safety Code® (LSC). Too many accreditation coordinators leave EOC and LSC standards up to engineers, Patton said, but these are major points of emphasis for The Joint Commission. For example, a “busted plan” or failure to institute interim life safety measures (ILSM) will cause an immediate downgrade to conditional accreditation. Start by reviewing Statement of Conditions dates and reviewing ILSM documentation, Patton says.

2. Partner with your lab director. Ignoring the hospital laboratories can be a big mistake, Pejakovich said. “You should be performing tracers and trackers in your labs just like anywhere else in the hospital,” she adds.

3. Look outside of the OR for time-outs to prevent wrong-site surgery. “When in doubt, perform a time-out,” Pejakovich said.

4. Be realistic with your pain policy. Using the appropriate pain assessment as part of the initial evaluation is the most important aspect of this standard, Patton said. If the assessment isn’t appropriate for the patient, it won’t help you be successful.

5. Involve HR in updating records. HR may complain about trying to perform primary source verifications, but it can take less time than collecting and copying licenses, Patton said. HR may also best be suited to monitor license expiration dates as well.

6. Keep up with technical requirements. This specifically refers to Accreditation Participation Requirements (APR), such as APR 8, which requires organizations to inform patients that they have the right to contact the organization’s management about any concerns they may have. This also includes updating The Joint Commission about changes in leaders and contacts and keeping up to date about extranet content.

7. Know your ABCs. This refers to the scoring grades of A, B, and C. Know the differences between the letters, and be sure to score each standard appropriately during your mock surveys. Remember that with an A policy, one failure equals an RFI, so your performance must be 100%, Patton said. If The Joint Commission has an EP scored at an A, you must have a policy for it, he said. “Even if the policy only says, ‘We do not permit physicians to bring their own medications into the hospital to give out,’ you still need to say you don’t allow it.” And with B standards, remember that you get to design the process. “Defend your process when appropriate, and never throw your policy under the bus if you think it fits the standard,” said Patton.

8. Fix it or find another way. If staff members can’t adhere to a policy, you’re allowed to change that policy or your technology. For example, if you require staff members to check and log refrigerator temperatures every day, that will inevitably be missed sometimes, and it is obvious to surveyors if they see one day missed on a check-off sheet. If staff members can’t do this every day, find a system that keeps a log electronically, Pejakovich said.

9. Monitor more than critical lab values. Most hospitals have a way to identify which lab values are critical, but you must also have a system for identifying which tests are always critical. “If you just say stat tests, people may take that for granted,” Patton said. “Maybe you need to have a category ‘super stat’ for tests [for which] you need the results immediately every time.”

10. Keep policies and procedures and medical staff rules and regulations in sync. Prior to drafting or revising policies and procedures, always review Joint Commission standards, CMS standards, state health department requirements, existing hospital polices, and med staff bylaws, rules and regulations, and policies.

11. Do the full periodic performance review (PPR), and use it more effectively. The full PPR will prepare staff members for an unannounced survey better, and the results will be taken more seriously than if you score everything yourself, Patton said. “It may be painful the first time and more work, but it will give you a more accurate sense of what you need to fix.” Also, once you create an action plan from the PPR, be sure to stay with it until it is fixed.

12. Don’t do it just for The Joint Commission. Standards and goals aren’t there just to make your life miserable, Pejakovich said. They are there to increase patient safety, help prevent medical errors, and improve the quality of care and service. Remind staff members of these reasons when creating and implementing new policies and procedures. If a policy seems to decrease patient safety but helps you comply with a goal, you need to go back and reassess what you’re doing.