Just before the second COVID-19 surge hit at the end of 2020, The Joint Commission (TJC) was completing about 10 percent of its scheduled on-site surveys. By the time full survey activities resume (which is not likely until May 2021 or after), TJC will be at least a full year behind schedule. TJC and other accreditors will need to use novel approaches to work through the backlog.
TJC has been experimenting with virtual survey activities to help close the gap. They have learned that many elements of surveying can be completed successfully without the survey team being on site. Some reviews, such as clinical laboratory surveys, are completed entirely via remote connection: documents are reviewed, interviews are conducted, machinery is inspected, and the survey report is prepared without the surveyor ever visiting the lab.
Some of these virtual survey activities may fade away as the pandemic loses steam; other virtual survey elements are likely to become a permanent part of the process. The “virtual document review” is almost certain to become a permanent change and has the potential to leave many hospitals vulnerable to adverse accreditation actions.
With more than four decades of experience, Bud Pate is a nationally recognized expert in CMS and Joint Commission compliance, process simplification, clinical quality, and patient safety. He works with healthcare organizations across the country to achieve sustainable, common sense solutions that promote efficiency, protect patients and comply with external regulatory requirements.
Off-Site Document Review – Why It Matters
We expect the seemingly trivial shift to off-site document review sessions to herald significant changes to the focus and severity of survey findings. Whereas environment of care/life safety (EoC/LS) surveyors have always had plenty of time for a structured and thorough review of EoC/LS documents (reflected in the mountain of EoC/LS findings in a typical survey report), clinical and leadership surveyors have had little time or structure to facilitate a comprehensive documents review:
The Joint Commission is getting serious. With more time and structure allowed by pre-survey virtual document reviews, the challenges above will be resolved. As issues identified during previous Joint Commission or state/CMS surveys reappear on subsequent surveys, the Commission’s focus will be on leadership. And persistent failures of leadership will ultimately result in denial of accreditation.
More Time, More Focus, More Risk
With the growth of the pre-survey virtual documents review session, clinical surveyors will have the time and structure to thoroughly and consistently review past state/CMS survey findings, minutes of key oversight committees, critical policies and plans, and other documents important to the survey process. What does this change imply?
New Process Could Bring Positive Outcomes
While a virtual document review process may seem daunting, we believe it will enable more consistency between survey teams, allowing the hospital to maintain focus on significant areas of vulnerability from year to year and survey to survey. Leadership will have an additional incentive to focus on significant vulnerabilities rather than being distracted by a flood of less impactful findings. The enhanced focus on consistent, sustained compliance should result in lasting improvements to problem prone processes. It should also help most hospitals abandon the “whack-a-mole” approach to survey preparation in favor of a more focused and enduring improvement process, leading hospitals toward high reliability.
What To Do
We’re all learning how to do things differently as a result of the unprecedented year 2020. Preparing for the more in-depth review of leadership effectiveness signaled by the virtual survey documents review process is just one sign of change. This shift in TJC’s focus toward sustained compliance with high-risk requirements has been in progress for years. It is incumbent upon your organization’s accreditation readiness efforts to change accordingly.
Identify truly significant survey findings. TJC’s SAFER matrix helps identify the 25% of RFIs that are considered of higher importance (the top 6 SAFER categories: from Immediate Threat to Life to a Pattern of observations with a Moderate likelihood to harm). But don’t stop at SAFER scoring. Sorting should also address whether individual findings are inaccurate (red herrings based on the survey team’s or the organization’s misunderstanding of the issue or the underlying requirement), “one offs” (a valid but infrequent imperfection in an otherwise solid process), or the reflection of a significant failure of an essential hospital system.
Identify the organizational defects that underlie the significant flaws in hospital systems identified in Step 1. Are these defects caused by flaws in Process Implementation (the clarity and practicality of policies and procedures, the effectiveness of medical records documentation, staffing levels, management effectiveness, etc.), Monitoring (the focus and relevance of metrics and adverse events analysis), Communication (change management, just culture, culture of safety, communication of organizational risk, etc.), Oversight (streamlined oversight structure, alignment of executive leadership, accountability assignment and follow through), or a combination of these?
In the past, the typical response to a survey finding was to make something more complex at the point of care and service. We added pages to policies, indicators to quality plans, and checkboxes to electronic records. But complexity increases error, so it is essential that problem prone systems be as simple and repeatable as possible. For example: the relevant policy and procedure should contain simple, practical expectations; performance monitoring should be focused on actual practice; performance feedback should be concurrent, supportive, and data driven; and documentation should be simplified with an emphasis on communication.
The journey toward sustained compliance and organizational reliability is a marathon. It is not a mock survey or the acceptance of a plan of correction / evidence of standards compliance. It is a day-by-day, year-by-year process of inching closer to the Hippocratic ideal “… first, do no harm.” For compliance is nothing more than safe and efficient patient care and service. And success on surveys depends on the non-trivial task of connecting compliance with quality, safety, and efficiency.