The Greeley Company
May 31, 2019 11 Min Read

The Top 10 Things Your Hospital Can Do to Avoid and Cope with a Joint Commission Survey Disaster

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What are the Odds of a Medicare Deficiency after a Joint Commission Survey?

Your hospital has a 50-50 chance of being in serious trouble when the survey team walks out of your door at the end of your next full Joint Commission survey. That means half of accredited hospitals will also need to prepare for a Medicare Deficiency Follow-up Survey (MED DEF) about 45 days following the summation conference. Some will also need to prepare for 60-day and 4-month follow-up Joint Commission survey to resolve Preliminary Denial of Accreditation.

The Bigger They Are …

The bigger the hospital, the greater the vulnerability:

  • The bigger the hospital, the more surveyor days.
  • The more surveyor days, the more Requirements for Improvement (RFIs).
  • The more RFIs, the more likely the team will find a condition-level deficiency, or worse.

This “the bigger they are …” rule is somewhat offset by the resources larger hospitals usually have for survey preparation and management.

The Top 10

This blog post addresses the ten most important things your hospital can do to avoid and, if necessary, cope with a Joint Commission survey disaster. However, this is a big issue, so Greeley is also hosting a free webinar that will cover the nuances of survey disasters. Click HERE for more information.

This post begins with the six things you need to do during a survey and after receiving the bad news, followed by four things your hospital can do to avoid the survey disaster in the first place.

Coping with a Joint Commission Survey Disaster: Items 1 through 6

1. Resolve Issues During Joint Comission Survey

Take the time to arrive at a mutual understanding of significant survey findings while the survey team is on site. Take as much time as you need – it’s part of the process. Call an expert if necessary to resolve the issue before you see the survey team’s tail lights vanish in the distance on the last survey day.

If you don’t understand a finding, ask.

If you don’t agree with a finding, say so.

2. Address Condition-Level Findings Right Away

Surveyors tend to be very good about giving hospital leaders a “heads up” during the survey when they think your organization is at risk for adverse actions. Page 3 of the preliminary survey report will clarify your status.

If Page 3 has “Unannounced Medicare Deficiency Survey” under “Follow-up Activity,” your survey report has one or more condition-level deficiencies. The Joint Commission will be back in 45 days to review a subset of findings on your report.

Which findings will they look at? Page 4 of the survey report makes that clear. The Joint Commission will focus on the findings with a check mark in the column labeled, “Included in the Medicare Deficiency Survey” when they return in 45 days.

Immediately start to focus on these checked items. Typically, about 10 to 20 findings out of roughly 50 or so findings in your report.

Preliminary Denial of Accreditation

A growing number of surveys also trigger rule PDA 02: Preliminary Denial of Accreditation due to the number, severity and repetitive nature of the survey findings.

It’s unlikely that a hospital will receive PDA 02 determination without also having a MED DEF follow-up survey. So, begin focusing on the MED DEF issues (Page 4 check marks) first:

  • begin correcting,
  • draft clarifications, and
  • gather evidence.

3. Always Clarify…. Always.

A myth persists that the Joint Commission no longer accepts clarifications … a myth created when the Joint Commission abolished Type C Requirements for Improvement, which allowed the hospital to clarify or remove a Requirement for Improvement (RFI) by showing 80% – 90% compliance through an audit of records available at the time of a survey. The Commission also stopped accepting evidence of compliance that was not made available to the survey team while they were on site.

However, almost all survey reports have RFIs that should be clarified because they are inaccurate or unclear. Roughly one-third of the RFIs on an average survey report misstates the situation, misquotes the requirement, do not make sense to the organization, or have other inaccuracies (such as referring to an address not visited).

Take the time (10 working days after receipt of the “final” report) to submit clarifications. The date of your MED DEF survey will not change, a surveyor (infrequently more than one) will return to your hospital about a month and a half after the original survey, but you’ll find it easier to show compliance if you’ve worked through misunderstandings before the surveyor(s) arrives to follow up.

The Standards Interpretation Group (SIG) typically denies most clarifications on the first pass. Use this as an opportunity to better understand the situation in a follow-up call with SIG after you receive their letter. In our experience, most of the originally-rejected clarifications are either removed or truly “clarified” (all parties have a better understanding of what compliance looks like) after a follow-up call.

4. Operational Focus

Meet daily to focus on the subset of RFIs that will be reviewed during the 45-day MED DEF survey (from Page 4 of your report). Progress should be reported to the executive team at least once a week.

We recommend using an online tool like Google Sheets or SmartSheet to develop action plans. (Some IT departments prefer SmartSheet because of security considerations.) We do not recommend the typical approach of a stand-alone Excel spreadsheet. Version control and access to evidence can be a large issue with a stand-alone spreadsheet.

Some repairs to the physical environment may take longer than 45 days. The Joint Commission will give the hospital 60 days to fix some things, but you’ll need to negotiate an exception or waiver if it will take longer.  Begin working with the Joint Commission immediately on issues that will not be completely fixed before the MED DEF survey. Your Account Representative will help.

5. Gather Evidence

Fact 1: Surveyors will not have a lot of time when they return for the 45-day MED DEF survey, so they appreciate having all evidence of compliance readily accessible in one place.

Fact 2: Hospitals do not like surveyors wandering through their buildings, so survey coordinators also appreciate having all evidence of compliance readily accessible in one place.

So win-win: gather evidence for all MED DEF findings in a comfy conference room with coffee and snacks, and:

  • Prepare an “evidence of standards compliance” (ESC) statement for each RFI to be reviewed during the MED DEF survey.
  • Attach images, audits, policies, and other documents to your on-line tool next to ESC statement for each RFI.
    • An alternative, which is not as efficient, is to create a computer filing system with folders and subfolders to capture evidence.
  • Don’t expect the surveyor to go through the on-line tool or folder system. Have the collected evidence in binders separated by tabs labeled with the Joint Commission standard and Element of Performance (EP).
    • Have a separate tab for each EP.
    • Have a separate tab for each observation under the EP when there is more than one.
  • Have content experts present in a “war room” nearby the surveyor’s workroom so they can be immediately available to walk the surveyor through any questions they may have about the actions taken.
    • If possible, cluster the evidence review process by the associated subject matter expert. For example: cover the three things for the emergency department director, then go to the four things for the patient safety officer, then the five things for the infection control practitioner, etc.

6. Plan for the Next Survey

If your survey triggered Preliminary Denial of Accreditation (PDA), you will have to prepare for another onsite visit: 60 days from the date of the first (pre-clarification) “final” report or 2 weeks after the MED DEF survey. If your 60-day survey goes well, you will have another survey in 4 months and your next triennial survey will be moved to the beginning of the survey window.

If your survey did not trigger a PDA, you will need to submit Evidence of Standards Compliance in 60 days.

Simplify and Comply

Either way, sort your findings into three categories:

  • One-Off: observations of isolated defects in a good system;
  • Inaccurate: the observation was not valid but it was not removed from the report through the clarification process; and
  • Systems Issues: truly flawed systems or processes.

One-Off Findings.

Do not attempt to change your system by making existing expectations (policies, procedures, etc.) more complex. Remind people of existing expectations and continue to monitor using existing measures. Dedicating resources to one-off findings will not improve the situation and often takes needed attention and resources away from larger issues.

Inaccurate Findings.

Do not attempt to change your system by making existing expectations more complex. Remind people of existing expectations and continue to monitor using existing measures. Dedicating resources to inaccurate findings will not improve the situation and often robs needed attention and resources from larger issues. (You may have noticed, this is the same as our approach to One-Off Findings.)

Systems Issues:

Simplify and Comply. Making things complex is very easy. Making things simple takes a lot of time and requires expertise and skill. However, simplification is essential since processes that are unnecessarily complex are usually not followed.

Realize that fixing a flawed system will take longer than the 60 days allotted by the survey agency, so plan some interim steps to compensate for the flawed system as you take the time to truly fix it.

Repeated systems issues can lead to true and final Denial of Accreditation. First, make sure it’s a legitimate systems issue, then take the time to fix it once and for all.

Avoiding a Survey Disaster (Items 7 through 10)

The following 4 items will help you avoid landing in the unlucky 50%.

7. Environment of Care and Life Safety

Environment of Care (EC) and Life Safety(LS) issues account for the majority of survey findings.

Reports to the oversight committee(s) should be focused on the true systems issues rather than the one-off and inaccurate findings mentioned above.

Current EC issues that lead to a condition-level finding include:

  • Ligature resistant construction in behavioral health settings;
  • Temperature and Humidity in the operating rooms; and
  • Air flow in sensitive or “critical” areas.

The list of EC and LS heavy hitters changes over time, so it’s important to stay connected to Greeley and similar resources to help you separate common systems problems from frequent one-offs and inaccurate findings.

True systems issues related to the environment of care should be on the executive team’s agenda.

Greeley offers frequent workshops on high-risk environment of care issues. Our most recent workshop on Ligature restraint is available on-demand here. 

8. Suicide Prevention

At least for now, flaws in the identification and protection of patients who are at high risk for suicide account for many condition-level survey findings. The largest problem we find is that organizations over commit and under perform.

Greeley has a separate workshop on this ever-changing issue that includes simple tools for all settings. We find most hospitals create unrealistic expectations for screening and assessments that cause patients to be on precautions (such as 1:1 observation) that are neither indicated nor consistently implementable.

Each hospital should thoroughly understand suicide prevention requirements and take the time to create a simple, appropriate, safe, and implementable solution. Watch our seminar on suicide assessment and prevention on-demand here.

9. High-Level Disinfection

There is a reason high-level disinfection has remained problem prone in recent years (and often leads to MED DEF follow-up surveys or worse). Check out these Greeley resources and our Simplify and Comply workshop on Infection Prevention: Disinfection and Sterilization:

Always remember to:

  • Pay attention to participants in the entire disinfection / sterilization cycle, not just the disinfection / sterilization segment;
  • Invest in a comprehensive disinfection / sterilization gap analysis; and
  • Develop a long-term improvement plan that takes the pervasive nature of disinfection / sterilization into account.

10. Everything Else: Focus and Simplify

Many hospital leaders and survey coordinators think “if I can just identify all of our vulnerabilities and fix every one of them then I’ll pass the survey with ease.” Therefore, they focus on issue identification, which is never-ending and usually leads to overload and paralysis. Fixes to “everything” are usually ineffective. Many of the things hospitals try to fix were not broken in the first place.

Instead, we recommend focusing only on true systems issues. There are more systems issues than we have the time and resources to address, so they must be prioritized.

The approach to fixing a true systems issue is to make the process easier to understand and implement. The easy thing to do should be the right thing to do.

Remember, compliance is nothing more than the consistent implementation of safe and efficient practices. If you don’t understand the real (not imagined) operational connection between compliance and safety, you will not succeed in sustaining your solution. Creating sustainable improvements to flawed systems takes experience, expertise and skill.

The Greeley Company team is available to help you solve these difficult problems in the months and years to come. For more information about how Greeley can help accelerate solving your challenges with practical solutions, you may contact us at 1.888.749.3054, email us at or complete the form below to start the conversation.

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