Question

Your facility is expecting a Joint Commission survey in the next year. You have several new employees that have never experienced this survey process. These employees would like a better understanding of their role in the survey to ease their anxiety about it. Create an outline of the survey process detailing the typical steps of the survey process so that your employees will know what to expect.

Answer 1

#. Joint Commission on Accreditation of Healthcare Organizations :-

Evaluates and accredits nearly 15,000 health care organizations and programs in the U.S.

Independent, not-for-profit

"State-of-the-art" standards

Conducts on-site surveys by a survey team at least once every three years (Labs surveyed every two years)

#. What type of organizations does the Joint Commission provide evaluation and accreditation services to :-

*General, psychiatric, children's and rehabilitation hospitals

*Critical access hospitals - Durable Medical Equipment (oxygen tanks, wheelchairs, etc.)

*Medical equipment services, hospice services and other home care organizations

*Nursing homes and other long term care organizations

*Behavioral Health care organizations, addiction services

*Rehabilitation centers, group practices, office-based surgeries and other ambulatory care providers

*Independent or freestanding laboratories

#. What should be prepared for a hospital survey :-

Know the standards

Examine current processes

Improve areas that are not currently in compliance

Comprehensive Accreditation Manual for Hospitals (CAMH)

Attend seminars to understand standards

Network with colleagues

Do a mock survey before you have a survey for critical feedback (for improvement & recommendations)

#. The AREAS OF FOCUS of the Joint Commission Survey/ AKA THE MAIN FOCUS :-

Ethics, Rights and Responsibilities: Patient rights, confidentiality, privacy, organizational ethics, how to obtain interpreter services . National Patient Safety Goals (NPSGs)

*Provision of Care, Treatment and Services: Assessment, planning care, providing care, pain management, nutritional care, patient/family education, entry to care and services, discharge planning, continuum of care, end-of-life care, diagnostic services and waived testing, operative or other procedures and moderate or deep sedation or anesthesia

*Medication Management

*Surveillance, Prevention, and Control of Infection

*Improving Organization Performance

Leadership

*Management of the Environment of Care: Fire safety; security; surveillance, prevention and control of infection

*Management of Human Resources: Job descriptions, provision of qualified people to fulfill roles, assessing staff competencies, educational opportunities, annual health review

*Management of Information

*Nursing Staff (training & qualifications)

*Medical Staff (training & qualifications)

#. What should staff do during a survey situation :-

*Avoid general or vague words or phrases, such as "sometimes", "usually" or "the way I do it is...."

*If you do not understand the surveyor's question, ask for clarification ("Could you restate the question please")

*If you do not know the answer, say so, but explain how you would find out (state, "I am not certain of that answer. I would refer to our policies and procedures manuals or consult my manager")