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Joint Commission Survey Readiness for 2009
By Karen Meno, MBA, RD, LD, CPHQ, HCRM
Today’s Dietitian
Vol. 11 No. 5 P. 48

You know the surveyors are coming, but you can’t be sure when. Facilities used to know the general time frame when they would need to be ready for inspection by The Joint Commission (formerly JCAHO; now abbreviated as TJC). Now, all triennial surveys are unannounced—facilities receive only 30 minutes’ notice. On the day of the survey, TJC announces that day’s schedule on its extranet Web site. The survey is the equivalent of a pop quiz, except that it’s more important than a quiz.

TJC is counting on its policy of surprise visits and the changes made for 2009 to add to the credibility of the survey results by allowing its surveyors to see a facility as it functions on a daily basis. It believes that allowing no time for last-minute preparations will end what many see as “gaming” the system—cramming for the exam, so to speak, without truly understanding the material.

This article will explore how survey teams will function in 2009 and what you can do to prepare. Obviously, you must start by “hard wiring” key processes so they occur 100% of the time. Embedding standard compliance into your daily process is the key to success. It is imperative to stay on top of the standards, interpretations, and standard changes. Before they are put into place, the proposed standards are posted on the commission’s Web site.

Changes for 2009
New for 2009 is the Strategic Surveillance System (S3), a scoring grid to track facilities’ success with compliance. Areas that contribute to the S3 include publicly reported outcome data, Core Measures publicly reported data, customer satisfaction data as recorded by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, also known as the CAHPS Hospital Survey), patient complaints reported to TJC, non–self-reported sentinel events, and scores from the last survey. Hospitals that score more than 300 on the S3 grid are more likely to receive a visit from the surveyors early in the triennial cycle. The lower they score, the better. Scores are updated quarterly and contain data from three rolling quarters.

The survey process includes five new chapters: Emergency Management; Life Safety; Record of Care, Treatment, and Services; Transplant Safety; and Waived Testing.

The standards are divided into two categories: direct impact requirements (direct patient care requirements) and indirect impact requirements (nondirect patient care requirements). Indirect standards are not included in the scoring; however, facilities must correct these deficiencies. There are 288 standards with 1,700 elements of performance, with expectations detailed. Of the 288 standards, 117 have direct impact elements.

There are no longer supplemental recommendations, only Requirements for Improvement (RFIs). At the end of the survey, the surveyors will provide a summary of the findings. A finalized report will take two to four weeks. Once the report is posted, facilities will have 45 days to submit their completed action plan.

Advance Notice
Standards are provided in the Comprehensive Accreditation Manual for Hospitals: The Official Handbook from TJC. Many standards contain a future implementation date. Staying ahead of implementation dates ensures preparation for unannounced surveys. The 2009 functions are organized as follows:

• Patient Rights and Organizational Ethics;
• Provision of Care;
• Improving Organizational Performance;
• Leadership;
• Environment of Care;
• Life Safety;
• Human Resources;
• Information Management;
• Record of Care, Treatment, and Services;
• Infection Control and Surveillance;
• Medical Staff;
• Nursing;
• Medication Management;
• Patient Safety Goals;
• Emergency Management;
• Waived Testing; and
• Transplant Safety.

All standards are founded on evidence-based medicine and real-life hospital experiences that have been substantiated with data. Thus, when preparing your policies and procedures, you should include a reference section at the end to demonstrate that your decisions and processes are based on research. Listing the function in the policy header or reference section is also recommended.

Policies and procedures created arbitrarily are unacceptable; they must be supported by standards of care in the community and evidence-based medicine. Researching literature, using the Internet, and using experts as resources provide a platform to build your own processes. Often, you can improve on the work of others while tailoring it to your own facility.

Use the experts. Doing so ensures a smooth survey and limits your RFIs. Many Web sites discuss the latest and best methods to provide patient care, including those for the Institute for Healthcare Improvement (www.ihi.org), The Leapfrog Group (www.leapfroggroup.org), and the National Quality Forum (www.qualityforum.org).
The Centers for Medicare & Medicaid Services contracts an entity in each state to oversee quality for that state.

Teamwork
Structure helps ensure a state of constant readiness and, because many processes are interdisciplinary, establishing a policy and procedure review team is a great way to keep projects moving forward.

Ideally, this team would meet every two weeks, and members would include those to whom the policy relates. Each discipline would submit policies for the agenda, with drafts of the policy sent in advance and brought to the group for fine-tuning. This strategy prevents projects from being unexpectedly derailed due to a lack of interdisciplinary communication. Buy-in by all creates a smooth transition when the new or revised processes are put in place. Each discipline can educate its own department regarding process implementation.

All policies should be placed on a calendar for yearly review and/or revisions as needed. Because our environment changes so rapidly, all policies should be reviewed annually. All staff need online access to the facility’s policies and procedures; by not granting access, the facility may face declines in quality of care.

Reinforce changes via hospitalwide e-mails and newsletters. Minutes of each meeting may be kept and distributed to each team member, department director, and senior manager to ensure everyone is aware of the progress and to provide support for any process changes.

Using Tracer Audits
Another way to maintain a state of readiness is to use practice “tracers” to monitor a patient’s care throughout his or her stay. The choice of patient depends on the types of services your facility provides, and the patient should be one who is representative of the facility. For example, if your patients are primarily older adults, the patient should be one who has a common diagnosis of this age group, such as acute myocardial infarction, congestive heart failure, or community-acquired pneumonia. For surgical specialties, the patient should be one who has undergone procedures your facility provides, such as coronary artery bypass graft, knee replacement, hysterectomy, or colon resection.

An interdisciplinary group should then ensure that each step in your patient care process had been completed and documented. General patient and specialty tracers for infection control, data, and medication management are defined by TJC. Tracers move from department to department and follow the path the patient takes. For example, the tracer may start in the emergency department and then move to the intensive care unit, a nursing unit, surgery, and postanesthesia care. The tracer may visit the pharmacy, the respiratory department, and the food and nutrition department, depending on the services the patient uses.

Clinical dietitians should be readily available to practice answering common surveyor questions about their assessment, reassessment, and education. All disciplines must demonstrate adequacy of documentation and communication with other disciplines.

Pocket Guide Tool
Another strategy is to create a pocket guide resource book for employees to carry and have available at key locations. The booklet should be organized by the commission’s functions and serve as a handy resource for review and ongoing use. Hospitalwide information that all employees need to know is contact information, who the safety officer is, and the emergency codes. Each function contains discipline-specific information. For example, on the advanced directive process: Is it honored in inpatient and outpatient areas? Where in the record is the form kept? What do you need to do if, for example, a patient collapses and stops breathing during a diet counseling session?

If a surveyor asks you a question that you cannot answer or you become too nervous to give your best answer, you can say, “Let me check my pocket guide.” It is OK to admit that you do not know the answer, as long as you know where to find it.

Tips for Success
The following suggestions will help you succeed with your next unannounced survey:
1. Be confident. Answer only the questions that are asked; do not offer extra information.

2. Smile and maintain a positive attitude.

3. Don’t hide from surveyors; approach them. Gather your team around you. After all, there is power in numbers.

4. Pause before answering questions and reflect on them briefly to ensure you understand them. If you find a question confusing, ask the surveyor to rephrase it. If you don’t know an answer, admit it, but always be aware of where to find the correct answer. The pocket guide can include references for more detailed, definitive information.

5. Know the processes that apply to you inside and out and be prepared to answer questions about your job responsibilities, training, and patients. Refer to specific policies and procedures that apply to your function. Be aware of hospitalwide policies and procedures that apply to all employees.

6. Provide examples when appropriate. Mention quality improvement teams, patient safety projects or committees, and process improvement work. Emphasize teamwork.

7. Be prepared to demonstrate what you know. Surveyors may wish to observe a specific task.

8. Take a few deep breaths and try to remain calm. Be proud of your facility and what you do.
If this advice sounds like the kind an attorney gives a witness, it is—but a survey is not a trial with a guilty or not guilty verdict at the end. Think of it as a process of improvement, as TJC intends it to be.

Keep in mind that you are not in this alone. Confer with colleagues in other facilities that have been through surveys in the same calendar year, since sharing information can create successful surveys for all. Develop relationships with colleagues at professional associations, and use the Internet to share documents and research articles. Obtaining several policy or form examples and improving on them creates a better product.

9. Protect against imposters. Believe it or not, several facilities have reported surveyor imposters. TJC has responded—legitimate off-shift or weekend survey visits have been largely suspended (but are still possible). When surveyors arrive, you should always validate their identity. Surveyor names should be on the facility TJC extranet by 7:30 am the day of the survey. Each surveyor should have an official TJC badge.

TJC Glossary
TJC uses acronyms specific to the accreditation process, and sometimes it’s easy to get lost in this “alphabet soup.” The following are key acronyms and definitions that will help you better communicate with surveyors and help you understand the survey process:

• DIR (Direct Impact Requirement): Direct patient care requirements. Included in the RFI accreditation threshold number.

• IIR (Indirect Impact Requirement): Nondirect patient care requirements. IIRs are not included in the accreditation process threshold number; however, facilities must correct these deficiencies.

• PPR (Periodic Performance Review): An annual assessment of standards to identify areas needing improvement is required. You may perform a self-assessment or ask a TJC surveyor to come on site to perform the assessment.

• ESC (Evidence of Standards Compliance): Confirmation or verification that illustrates or proves how an organization is in compliance with a standard. Policies and procedures, protocols, teaching outlines, logs, tests, observations, evaluations, and data may prove compliance.

• POA (Plan of Action): A plan detailing the actions an organization will take to comply with a TJC standard. If in response to an RFI, an MOS may be required.

• MOS (Measure of Success): A numerical or other quantitative measure usually related to an audit that validates whether an action was effective and sustained. It must be defined; systematic or random sampling is used. Data for four months are usually submitted to TJC showing a track record of 90% to 100% compliance. A circle around the letter “M” in the Comprehensive Accreditation Manual designates the elements of performance that require an MOS. An internal use only MOS is recommended to show compliance of a new or difficult-to-meet standard.

• RFI (Requirement for Improvement): These are standards deemed to be noncompliant.

• EP (Element of Performance): The scoring criteria used to assess compliance. A more detailed description follows the standard summary. Scoring: 0 = insufficient; 1 = partial; and 2 = satisfactory.

• PFA (Priority Focus Area): These are processes, systems, or structures in a healthcare organization that significantly affect the quality and safety of care. Surveyors use the PFA to plan on-site survey activity and agendas. The current PFA categories include infection control, medication management, information management, assessment and care of services, communication, credentialed practitioners, equipment use, organizational structure, orientation and training, patient safety, physical environment, quality improvement, staffing, and patient rights.

• PFP (Priority Focus Process): The process for standardizing the priorities of an organization’s survey based on information collected about the organization prior to the survey. The process helps focus the survey on areas critical to that organization’s patient safety and quality of care processes.

• CSG (Clinical Service Group): Categories of patient for services that are either high volume for the organization or considered high risk or problem prone by TJC. Surveyors will use an organization’s current patient list by diagnosis to identify the CSG to select patients for tracer activity.

Patient Safety Goals
TJC National Patient Safety Goals are updated annually based on sentinel event occurrence data and research. A sentinel event is defined as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” Such an event is called sentinel because it signals the need for immediate investigation and response. For example, a patient dies after falling out of a window on a hospital’s sixth floor. Possible root causes are investigated: Were suicide precautions in place? Was the patient confused and not monitored? Were the windows locked or unable to be opened correctly?

The goals are created based on expert, systemwide solutions to the identified problem areas. Retired goals are moved to other locations in the standards and are still scored. The 2009 goals are as follows:

• Improve the accuracy of patient identification. Use at least two identifiers, excluding the patient’s room number.

 

• Improve communication among caregivers. For verbal or telephone orders or the reporting of critical test results or critical values, the person receiving the call must complete a “read back” verification process. That is, the person receiving the communication must write it down and read it back to the sender to ensure accuracy and then document the encounter by time and date. All communication should be timely and communicated to the physician within 30 minutes.

• Establish a standardized list of abbreviations, acronyms, and symbols that are not to be used throughout the organization. Do not use unapproved abbreviations (eg, QD, QOD, U, IU, trailing zero, lack of leading zero, MS, MSO4, MgSO4). Program your electronic templates not to include unapproved abbreviations and avoid use in free text. For example, do not use “U” for units of insulin. It can be misread as a 0 or a 4, causing a 10-fold overdose. Write out the word “units.”

• Implement a standardized approach to hand off communication. The same method should be used for each encounter, such as change of shift, level of care, or telephone conversations with physicians or other caregivers. An example is SBAR (Situation, Background, Assessment, and Recommendation). This should include an opportunity to ask and respond to questions at the end of the conversation, which ensures that complete updates of history, prioritized issues, goals, and pending results are discussed.

• Improve the safety of administering medications. Identify and annually review a list of look-alike and/or soundalike drugs used in the organization and take action to prevent errors involving the accidental interchange of these drugs. Label all medications, medication containers, or other solutions on or off the sterile field. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

• Accurately and completely reconcile medication across the continuum of patient care. Implement a process for obtaining and documenting an accurate and complete list of the patient’s current medications upon his or her admission. An accurate list is also created upon transfer to another level of care within the facility. An accurate and complete list must be reconciled at discharge, and a copy must be given to the patient and the list communicated to the next provider.

• Reduce the risk of acquired infections. Comply with current Centers for Disease Control and Prevention or World Health Organization hand-hygiene guidelines, which require the use of alcohol-based hand gels, forbid artificial nails, mandate the use of gloves, and prescribe good handwashing technique (a minimum of 15 seconds). All staff should be familiar with the guidelines and be able to verbalize them for surveyors. Wash your hands and/or use gel hand sanitizer upon entry or exit from patient rooms. A common instance of noncompliance is during tray delivery at mealtimes.

• Prevent multidrug resistant organism infections, central line-associated bloodstream infections, and surgical site infections.

• Reduce the risk of patient harm resulting from falls by implementing a falls reduction program and evaluate the program’s effectiveness. All disciplines should participate in preventing patient falls. Be aware of what is happening to your patients. Are they trying to climb over the bed rails to get assistance? Did delayed staff response to call lights cause their frustration? Be aware of your facility’s warning symbols used to designate falls risk (known as fall precautions). All disciplines must be trained in falls prevention.

• Manage events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection as sentinel. A root cause analysis (RCA) should be completed on all sentinel events or near misses.

• Encourage a patient’s active involvement in his or her own care as a patient safety strategy. Patients and families are educated on methods available within your organization to report concerns related to care, treatment, services, and safety.

• Identify safety risks within the patient population (eg, patients at risk for suicide) and take preventive precautions.

• Improve the recognition of and response to changes in a patient’s condition. A method must exist that enables healthcare staff members to seek additional assistance from specially trained individuals when the patient’s condition appears to be worsening. The Rapid Response Team should respond in a timely way to assist in recovery.
Patient safety is the responsibility of all employees. Be knowledgeable about how your facility meets these goals and prevents patient harm. Be sure to speak up if you see actions that promote an unsafe environment.

Problem-Prone Areas
The following areas have proven problematic in recent surveys. In 2008 into 2009, the following areas repeatedly demonstrated noncompliance:

• Record of Care, Treatment, and Services: Those facilities not using an electronic health record must date and time each entry in the medical record per the facility policy and procedure. This act is commonsense and protects the clinician by showing the sequencing of events. Diet orders must be transmitted accurately for tray content.

• Life Safety: Exits, exit accesses, and exit discharges must remain free of obstructions. Keep corridors and exits free of carts, equipment, and furniture. Do not block an exit under any circumstances. The doors must also open in the direction of the egress.

• Human Resources: The hospital verifies staff qualifications and must verify credentials with the primary source upon hire and renewal. This may be accomplished electronically or via phone with documentation.

• Leadership: When taking an order verbally, the clinician must document the order in the medical record, read it back, verify that it is correct, and document this act per hospital policy and procedure.

• Patient Safety Goals: See Patient Safety Goals section.

• Provision of Care: The hospital must define its assessment and reassessment guidelines in policy and procedure to include initial nutrition assessment and nutrition evaluations. The hospital policy includes the triggers, data, time frames, and screening tools that it uses. You must follow what your policy outlines, and you must set your time frames at a level that you can meet to include weekend coverage. Identify cases of malnutrition or areas of additional nutritional needs early. Quick intervention is critical to prevent problems.

Conclusion
Survey agendas are constantly modified based on daily findings during patient tracers and examination of data and policy and procedure documents. Two or more occurrences of noncompliance may lead to an RFI depending on the category of the standard. Direct impact requirements contribute to RFIs.

Not every facility scores 100%. Be gracious about receiving RFIs. Do not argue with surveyors under any circumstances. Calmly present any additional information or data that demonstrate you are in compliance 90% of the time. Consider all identified issues as diamonds in the rough; they are your opportunity to polish them into brilliance. Remember that these standards were designed to promote patient safety. After all, providing the best care for all is our ultimate goal.

Again, the best approach to survey success is the best approach to facility success: hard wiring your processes to promote absolute compliance. Ongoing monitoring is key. Procedures may become lax over time, or new employees may not be clear on the correct actions to support patient safety. Create internal quality improvement programs that facilitate education and promote compliance. Share results of studies at department meetings. Have the staff monitor each other. Your hard efforts will pay off with a successful survey. Be sure to celebrate your and your staff’s successes. Everyone likes to get a gold star.

— Karen Meno, MBA, RD, LD, CPHQ, HCRM, is the director of quality resources at Largo Medical Center in Florida. She has lectured on total quality management and performance improvement at seminars across the United States.

Learning Objectives
After completing this continuing education activity, the student will be able to do the following:

1. Explain the accreditation survey process.

2. Identify areas that contribute to the scoring grid for the Strategic Surveillance System.

3. Locate expert sources for determining the best methods for providing patient care.

4. Recognize components of an effective policy and procedure review team.

5. Be familiar with the usage of practice “tracers” for tracking patient care.

6. List tips to help achieve success at an unannounced survey.

7. Discern current patient safety goals.

 

Examination
1. Which of the following is true about The Joint Commission (TJC) surveys?
a. Surveyors must give notice that they are coming the day of the survey by 7:30 am.
b. Surveyors cannot visit without 24 hours’ notice.
c. Survey standards are retroactive to January 1.
d. Surveyors challenge your correct answers to trip you up.
e. Surveyors sometimes pose as patients or practitioners.

2. New standards are available for review prior to implementation:
a. on TJC’s Web site and in the Comprehensive Accreditation Manual.
b. on the Centers for Medicare & Medicaid Services Web site.
c. on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Web site.
d. on the American Hospital Association Web site.

3. All facility policies and procedures:
a. should contain content references.
b. should be evidence based.
c. should be research based.
d. should be summarized in a simple guide.
e. All of the above

4. If surveyors observe three or more episodes of noncompliance, it is an automatic supplemental Requirement for Improvement (RFI).
a. True
b. False

5. The following is true of the DIR (Direct Impact Requirement):
a. It is a direct patient care requirement.
b. It is included in the RFI accreditation threshold number.
c. It is a nondirect patient care requirement.
d. It is not included in the RFI accreditation threshold number.
e. a and b only
f. c and d only

6. The types of tracers utilized by TJC surveyors are:
a. an infection control tracer.
b. a general patient tracer.
c. a data tracer.
d. medication management.
e. All of the above

7. ESC is an acronym for:
a. Evaluation of Community Standard.
b. Evidence of Standards Compliance.
c. Evidence of Confirmation Scoring.
d. ESC in not a TJC acronym.
e. Evidence of Serious Complications.

8. A Measure of Success (MOS) is:
a. a numerical measure that validates that an action is effective and sustained.
b. a systematic or random sampling that may be used.
c. submitted to TJC to show compliance following an RFI, if requested.
d. done internally to ensure that you are meeting a standard.
e. All of the above

9. The following are National Patient Safety Goals:
a. Improve accuracy of patient identification.
b. Implement a standardized approach to hand off communication.
c. Reduce the risk of healthcare-associated infections.
d. Establish a standardized list of abbreviations, acronyms, and symbols that are not to be used throughout an organization.
e. All of the above

10. The Strategic Surveillance System (S3):
a. is a scoring grid to track the success of compliance for your facility.
b. includes publicly reported outcome data.
c. includes HCAHPS customer satisfaction data.
d. includes patient complaints reported to TJC.
e. All of the above