Post Survey Support
TJC Post Survey Support
Once your Joint Commission survey is over and you’ve received your official survey report, the next step is to develop and submit your corrective action plan to TJC. Depending on the results of your survey, this may mean submitting a written plan of correction or possibly also preparing for a resurvey.
Either way, our TJC post survey support provides the technical assistance you need to develop your response.
TJC Post Survey Support for Evidence of Standards Compliance
In Joint Commission terminology, your corrective action plan is called Evidence of Standards Compliance (ESC.) It must be submitted within 60 days of your official survey report.
For organizations seeking initial Joint Commission accreditation, TJC must first accept the ESC and then they grant accreditation. For psychiatric hospitals using Joint Commission accreditation for deemed status with CMS, TJC must approve the ESC and grant accreditation. Then, the hospital submits its TJC accreditation letter to CMS to gain approval for participation in the Medicare program.
Common Questions about Evidence of Standards Compliance
When developing their ESC, many behavioral healthcare organizations (especially those new to TJC accreditation) have several questions:
- What type of evidence of compliance is TJC looking for?
- How specific do we need to be about our corrective actions?
- How will TJC evaluate what we submit for our ESC?
- What type of documentation do they want to see?
- Must all my corrective actions be completed before we submit our ESC?
Technical Assistance with Your Evidence of Standards Compliance
Our TJC Post Survey Support helps you tackle the ESC process quickly and efficiently. We’ve worked with hundreds of behavioral healthcare organizations to develop ESCs that have been approved by TJC. We know the type of information they want and how best to format your ESC response so it meets all the Joint Commission criteria.
Once we analyze your survey report, we work side by side with you to address each of the required elements for the ESC to make sure TJC will accept it. We help you formulate your response so it addresses all the categories TJC requires:
- Assigning Accountability
- Correcting the Non-Compliance
- Ensuring Sustained Compliance
- Leadership Involvement
- Preventive Analysis
Benefits for your Organization
- You have an ESC that’s clear, comprehensive, and addresses every deficiency cited in your TJC report.
- You submit your ESC to TJC quickly and receive your accreditation approval ASAP.
- Your ESC serves as your roadmap for compliance going forward.
Joint Commission Post Survey Support for Adverse Decisions
Perhaps your organization has received an adverse decision from TJC. This might be Preliminary Denial of Accreditation (PDA), Condition Level Deficiencies, or an Immediate Threat to Life finding. If so, time is of the essence. The turnaround time for your corrective action plan is very short – 10 days for PDA. Plus you need to prepare for resurvey.
In these cases, we provide both onsite and offsite Joint Commission post survey support to tackle this challenge swiftly. We partner with your team and take the following actions:
- Prepare an appeal to TJC (called a Clarification) for any findings that appear ungrounded.
- Develop a robust plan of correction for each finding cited in your survey report.
- Conduct a focused mock survey to prepare you for your TJC follow-up survey.
- Organize the documentation you’ll need to show full compliance on your follow-up survey.
- When TJC conducts your follow-up survey, they get a crystal clear picture of how you’ve implemented your corrective actions. The evidence is there for them to see and your survey is off to a solid start.
- Your staff is prepared for the tracers and interviews the surveyors will conduct. They approach the follow-up survey with confidence.
Why Choose Barrins & Associates for your TJC Post Survey Support?
We’ve worked with behavioral healthcare organizations nationwide to address their TJC survey findings. We know how to develop successful ESCs and prepare for follow-up surveys. Our post survey support uses a proven approach to help organizations achieve initial Joint Commission accreditation or maintain their continued accreditation without interruption.