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Are you ready for the changes TJC has made to the survey agenda? TJC recently announced “minor modifications” to the survey agenda effective March 1st. Although they’re small changes, they do have implications for your onsite survey – and how you manage it. So, best to be fully prepared.

TJC Survey: Opening Conference

Up until now, the Opening Conference and the Orientation to the Organization were technically two separate sessions on the survey agenda. These are now combined. In addition, the time for this combined session is limited to one hour.

The important take-away here is your presentation for the Orientation to the Organization session needs to be brief and impactful. In other words, that means 15 minutes or less. The best preparation you can do is to script it, rehearse it, and time it.

Too many organizations deliver overly lengthy presentations. Frankly, these eat up the surveyors’ time when they need to move on with the agenda. Better to have a well-honed, concisely delivered overview that imparts the key points surveyors need to know about your organization.

These key points include your mission, goals, and strategic initiatives. Certainly, it’s also important to discuss challenges you’re facing. Better to address these proactively than have the surveyors encounter them firsthand during the survey process and not have the context for these issues.

In addition, be prepared for a focus on the culture of safety during this session. Surveyors want to know how you’ve evaluated your culture of safety. And, most importantly, what you did with the results. For more tips on this topic, see our post Evaluating Your Culture of Safety.

Another heads-up for this session: Be prepared for questions on how you handle “near misses.” Essentially, that means an adverse event that occurred which did not reach the patient but, if it had, might have caused patient harm. We’ve seen this question come up in several recent surveys.

So, be ready to discuss how you handle these “near misses” or “close calls.” Do you do an RCA? Or some other type of intensive analysis? They’ll want to see you have a consistent process in place for handling these adverse events.

TJC Survey: Surveyor Planning Session

The other change effective March 1st is the Surveyor Planning Session on the morning of Day 1 is gone. This session previously followed the Opening Conference and Orientation to the Organization.

Surveyors typically used this time to continue their Document Review and select their tracers. Instead, they’ll now begin conducting tracers right after the Opening Conference/Orientation to the Organization.

There are a couple of take-aways here. First, you’ll need to get your documents to the surveyors as soon as they arrive and are settled in their conference room. Clearly, they’ll be more pressed for time with the Surveyor Planning Session gone. So, they need to get started on those documents ASAP when they arrive.

For the specific documents required, see the Documents List in your 2020 Survey Activity Guide which is available on your TJC Connect extranet site. There’s one Documents List for Hospitals (surveyed under the Hospital Standards) and one for Behavioral Health organizations (surveyed under the BH standards.) For more tips on managing this session, see our post TJC Document Review Session: Survey Management Strategies.

The second take-away from the elimination of the Surveyor Planning Session is that surveyors will be out conducting tracers sooner than usual. Therefore, it’s critical to implement your tracer protocol quickly. Know who’s assigned as escorts and scribes. Also, alert the units where the tracers will occur so they can be ready.

TJC Survey: Special Issue Resolution

The change here is that at the end of the day, the Special Issue Resolution Session and the Surveyor Planning session have been combined. This is a minor change. However, there’s an important point to remember. If you need to clarify an issue with the survey team, you’ll need to claim some of that Special Issue Resolution time.

For example, perhaps someone gave the surveyor an outdated version of a policy. As a result, you want to provide the updated one and explain it to the surveyor. The Special Issue Resolution Session is the time to do it.

Most importantly, remember that TJC is approving very few Clarifications post-survey. So, the time to get things cleared up is while the surveyors are on site.

Barrins & Associates Resources

For more tips on managing your survey, see the other posts in our series on Survey Management Strategies:

When we conduct our Mock Surveys we simulate all these survey sessions and provide consultation on how best to manage each session. In addition, our TJC Survey Management Coaching provides in-depth technical assistance on the best tools and techniques for managing your survey and achieving optimal results. As always, our goal is to help you convey the quality of your services and how they meet the TJC requirements for patient safety and quality of care.