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Joint Commission Survey Focus

Recent Joint Commission surveyor training has given us guidance on where to focus survey readiness efforts.

If your hospital is accredited by The Joint Commission (TJC), your CEO recently received a letter. That letter alerts the CEO that Joint Commission surveyors have been given additional training in four subjects to focus on when they arrive at your door for a survey. These subjects are:

  • high-level disinfection and sterilization;
  • sterile compounding of medications;
  • identification and protection of potentially suicidal patients; and
  • hemodialysis.

Each of these is the source of many “Immediate Threat to Life” findings by TJC. Greeley has also found them to be the subject of many adverse actions by CMS. So, it behooves all hospitals to pay special attention to these areas (and not just immediately before your next survey window opens.)

TJC encourages hospital leadership to put these items on its agenda and to deploy resources with expertise in these areas to review and monitor performance. We agree. We also have some thoughts about how your hospital might go about it.

What To Look For In General

Greeley has learned from our experience helping hospitals work through hundreds of TJC and CMS adverse actions over the years, there are a few general principles that will help you get out and stay out of trouble. Paramount among these approaches (which are components of Greeley’s 14-point Framework for Sustained Compliance) are simple expectations, care facilitation, and effective oversight.

There are a few general principles that will help you get out and stay out of trouble. Paramount among these approaches are simple expectations, care facilitation, and effective oversight.

Simple Expectations

Don’t overbuild your policies and procedures. No one is able to understand or follow long and complex documents and you will be unable to monitor them. We understand, however, that these simple expectations are very, very difficult to craft. But that difficult work is necessary if you hope to avoid safety and accreditation vulnerabilities.

Care Facilitation

It is not possible to monitor performance in any of these areas through a simple review of logs or repeated training. If those approaches worked, these subjects would not be singled out for “enhanced survey” review.

Instead, one must understand the problematic steps in each of these processes (outlined in related blog posts) and combine monitoring and reinforcement in one step. We think of it as reinforcement with an open hand vs. a closed fist. Data are collected through the reinforcement process. It takes focus. It takes resources. But it does not take too much time: using this approach makes a real difference… quickly.

Effective Oversight

It’s difficult for large, multidisciplinary committees to be effective in closing the loop. So, although these “performance improvement committees” need to be involved, oversight must also be provided by the leadership team. In Greeley’s model, we recommend a final quality and safety oversight committee.

Convening the groups (or adding to the agenda of existing leadership team meetings) is the first step. Additional steps (effective presentations, realistic recommendations, accountability tracking, etc.) will increase the effectiveness of this group as it seeks to mitigate patient safety risks and regulatory/accreditation vulnerabilities. Greeley does a lot of work with clients on effective meeting management, or #enddeathbymeeting, as they call it in the Twitter-sphere.

Stay Tuned

You will see our summaries of common risk points in separate but related blog posts. Remember that none of these areas are new; they’ve been problematic for years. But now is the time to do something to address each of these once and for all. A good start is by following TJC’s recommendation: get these issues on leadership’s agenda (and stay tuned to Greeley for additional tips and advice.)

If you would like to schedule a mock survey focused on these stated focus areas, let’s start that conversion.



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