As we know, once the pandemic hit, TJC launched its virtual survey process. The number of virtual Joint Commission surveys increased dramatically over the past year as the Public Health Emergency continued.

Fast forward: TJC reinstituted routine onsite surveys effective March 15th. However, they’ll continue with a certain volume of virtual surveys in the near term.

In fact, several of our clients currently have virtual surveys scheduled. So, we’re providing an update on how these surveys are unfolding in the field. And how to prepare if you’re anticipating a virtual Joint Commission survey.

Virtual Joint Commission Surveys now “Offsite Surveys”

TJC has officially changed the terminology from “virtual surveys” to “offsite surveys.” The Behavioral Health Care and Human Services Accreditation Program has had one of the highest volumes of offsite surveys among all the accreditation programs.

Thus, if you’re accredited under the Behavioral Health Care standards, you have a higher chance of an offsite survey than a psychiatric hospital accredited under the Hospital standards. Of course, the best way to know about the plan for your survey is to be in close touch with your TJC Account Executive.

Offsite Survey Agenda

Several of our clients have undergone offsite surveys at this point. They’ve all found the process to be very manageable.

Clients report their TJC Account Executives have been very helpful in coordinating the agendas and uploading documents to the TJC SharePoint site. They also do a dry run with organizations on the videoconference technology. (TJC uses the Zoom platform to conduct their offsite surveys.)

Here’s a snapshot of a 3 day offsite triennial survey for a behavioral healthcare organization accredited under the Behavioral Health Care standards.

3 Day Agenda for Resurvey of Behavioral Healthcare Organization

DAY 1
8:00 – 8:30: Opening Conference & Orientation to Organization (including Infection Control and Emergency Management Discussion)
8:30 – 9:15: Document Review (Documents List in TJC survey Activity Guide)
9:15 – 9:30: Break (camera/sound off)
9:30 – 12:30: Individual Tracer Activity
12:30 – 1:00: Surveyor Lunch (camera/sound off)
1:00 – 4:00: Individual Tracer Activity
4:00 – 4:30: Special Issue Resolution or Surveyor Planning 

DAY 2
8:00 – 8:30: Daily Briefing
8:30 – 9:30: Data Management Session
9:30 – 12:30: Individual Tracer Activity
12:00 – 12:30: Surveyor Lunch (camera/sound off)
12:30 – 3:00: Individual Tracer Activity
3:00 – 4:00: Environment of Care, Emergency Management, Infection Control Session
4:00 – 4:30: Special Issue Resolution or Surveyor Planning

DAY 3
8:00 – 8:30: Daily Briefing
8:30 – 9:30: Leadership Session
9:30 – 12:30: Individual Tracer Activity
12:30 – 1:00: Surveyor Lunch (camera/sound off)
1:00 – 2:00: Competence Assessment Session
2:00 – 3:30: Surveyor Report Preparation (camera/sound off)
3:30 – 4:00: CEO Exit Briefing & Organization Exit Conference

Feedback from the Field

In addition, here’s some direct feedback from a client on their recent experience with their virtual Joint Commission survey:

Focus on COVID Response

“Our opening session focused heavily on our COVID-19 response. The surveyor wanted to know what we did to try and continue to serve our clients and keep everyone safe. We described how our outpatient services transitioned to tele-health. And what we had to do to accomplish that.

For our residential program, we described all the precautions we put in place and the PPE we purchased. We also told her about the staff training we did as well as training for our clients.

Our surveyor seemed impressed with all of that. But, when it came to documentation of our COVID response, we fell short. We had implemented a lot of things but we hadn’t really rounded back to our Safety Committee and analyzed all of this with them.

Luckily, the surveyor didn’t cite us for that. However, we took her recommendation and wrote up a critique of our COVID response and reviewed it with the Safety Committee. Based on that, we’ve made changes to our Emergency Management Plan that will help us in the future.”

Tracers

“The tracer topics were what we expected. There were three tracers on suicide risk. We fell short in that area too. We use the C-SSRS and trained the staff on that.

However, the surveyor found several cases where the risk level was high or moderate but there weren’t any interventions to address that risk level. We’re working on tightening that up now. Unfortunately, that finding was rated High Risk and Widespread on our SAFER matrix.”

Virtual Walk-Throughs

“We were surprised by the number of walk-throughs the surveyor did. She had us do a tour through one of our residences. We transported the PC we were using and she looked in clients’ rooms. We also had to take her virtually into our med storage room and show how we store client meds. She even had a staff member pull an over-the-counter med from the med cabinet and read the expiration date. Thankfully, it wasn’t expired!”

Outcomes Measurement

“We also had a finding on outcomes measurement. We use the BASIS-32 and have been aggregating our data on that for years. But the surveyor wanted to know how we use the outcomes data with individual clients. In other words, how we shared the data with clients and used it in treatment planning. We haven’t been doing that but are now researching how to tackle that.”

Lapse in Documentation

“We had a pleasant surprise about a lapse in documentation. Our PI Committee missed a few meetings in the early months of the pandemic due to everything we were working on with COVID. The surveyor saw that but didn’t cite us for it. She explained that her focus was on current operations. And that TJC is not focusing on documentation between March 1, 2020 and February 28, 2021. As a result, we got a break on that.”

Overall, our virtual survey experience was very positive. We got roughly the same number of findings as we did on our last survey which was in-person.

On the other hand, we’re actually looking forward to a regular onsite survey next time. There’s nothing like that in-person experience and we always learn a lot.”

Barrins & Associates Consultation

We’re now conducting our Mock Surveys and Continuous Readiness Consultations both virtually and onsite.

Client feedback has been that our virtual consultations have really helped staff feel more comfortable and prepared for their virtual Joint Commission surveys. As always, we’re prepared to support your ongoing compliance and survey readiness even in these challenging times.