Follow up – It’s Not Over When the Surveyors Leave


Even though there may be an audible sigh of relief when surveyors from The Joint Commission depart, in many ways the work is just beginning for those areas which received citations.   As is the case for Jacque Craig, MSN MBA BSN and many of her colleagues in the Quality Management Department.

“As with so many things, there is a lot of behind-the-scenes work before, during and after survey.  We work closely with The Joint Commission in the time between surveys to ensure we are in compliance; of course, a great deal is done during survey to provide everything the surveyors require; and the ‘aftermath’ involves focused and time-sensitive attention to meet all reporting requirements.  Also, this survey resulted in a few ‘Condition of Participation’ findings that required a re-survey.”

Two changes to the process this survey cycle added to the survey “to-do list” a requirement that the Sleep Lab be accredited separately, and the introduction of new survey methodology.

The SAFER Matrix is now used by TJC surveyors rather than the tracer methodology they have applied in the past.  Processes are subjected to a system of rating an observed regulatory infraction according to its severity and how widespread it may be.  For instance, if a Team Member is observed mislabeling a specimen, the surveyors would investigate further to discover if this error is confined to that particular Team Member, common on that Team Member’s unit, or if it is a process issue throughout the area being surveyed  – HRH, Home Health or the Sleep Lab.  The severity of the error is also assessed.  An error that appears to be a one-off, confined to that Team Member at that moment, and does not cause direct harm to the patient may result in a reference at the time and perhaps a mention during the exit conference, but will not be given a citation.  The more severe and widespread, the more likely an infraction is to be cited.

As noted above, there were a few Condition of Participation findings. These required an action plan to correct any deficiencies – something we are required to do for every citation, regardless of severity – and a re-survey to ensure that the corrections have adequately addressed the issue.  Most findings, however, required submission of an action plan without re-survey.  All involve audits to ensure any corrections made and process changes are hard-wired, with data collected and placed on a dashboard for easy viewing and assessment.  These results are monitored by the Quality Management Department and the Survey Readiness Team, and are elevated to review by Senior Leadership and the Board of Directors through the Patient Safety Subcommittee and the Board Quality Committee, who review the dashboard at their monthly meetings.  Once it appears full correction has been achieved, usually after 3-6 months of 100% compliance, audits will stop and data will no longer be reviewed.

Surveys ARE stressful, and it is easy to fall into an “us against them” mentality, but Jacque, a certified TJC surveyor, notes “The Joint Commission is paid by us to help us ensure we do everything possible to keep our patients safe.  In Quality, we view them as a resource rather than an opponent, and I encourage our team members to do the same.”