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Whether you have an onsite or a virtual survey, the Joint Commission Document Review is critical. Your documents give surveyors their first impression of your organization. And we all know “You don’t get a second chance to make a first impression.”

Thorough preparation for this session is key to your survey success. So, let’s review some survey strategies.

Joint Commission Document Review List

The TJC 2021 Survey Activity Guide contains Documents Lists for both the Hospital Accreditation Program and the Behavioral Health Care & Human Services Accreditation Program. This is your “go to” list for organizing your documents.

The Hospital Documents List is somewhat lengthy – 57 items. However, some are not applicable to psychiatric hospitals. In comparison, the BH Documents List is shorter – only 11 items on that list.

At the same time, it’s important to be aware that surveyors can ask for additional documents at any time throughout the survey. And they often do.

In fact, there’s a note on both Documents Lists that states: “Please note that this is not intended to be a comprehensive list of documentation that may be requested during the survey. Surveyors may need to see additional documents throughout the survey to further explore or validate observations or discussions with staff.”

When we conduct our mock surveys, we send a customized Documents List to our clients based on their setting and patient population. It includes both the TJC required items as well as documents that surveyors frequently request from psychiatric hospitals and behavioral health organizations. This helps minimize the impact of “surprise” requests for documents during TJC surveys.

Joint Commission Document Review: Organization is the Key

First and foremost: It’s critical that you closely follow the TJC Documents List and supply each item on that list (as applicable to your organization.) Make sure to label each document.

Also, use the terminology and the numbering system on the Documents List so the surveyors can easily match up your documents to their list. (The Hospital Documents List is numbered. Unfortunately, the BH Documents List is not.)

For virtual surveys, TJC will have you upload your documents to the TJC SharePoint site. This process will likely continue for onsite surveys as well. So, get ready to convert any paper documents to electronic formats.

Know Your Documents

With the uploading of documents, surveyors have a significant amount of time to review them. Much more time than when they had to rush through them on the first morning of survey.

That means they’ll become quite familiar with your policies, minutes, and data. So, be knowledgeable yourself about the documents you’re supplying. And familiarize other survey participants with those documents as well for the various survey sessions.

Here’s a recent take-away from one client: “The nurse surveyor had thoroughly read all the Pharmacy & Therapeutics Committee minutes for the last year. During the Medication Management session, she was asking questions about some of the data on med errors that was in the minutes. No one in the room was familiar with that. It was kind of embarrassing. Next time, I’ll have people review the minutes before they go into a meeting like that.”

Manage Your Documents

Make sure you identify one single source for supplying documents to the surveyors. We’ve seen scenarios where staff give a policy to a surveyor during a tracer that contradicts the one the organization supplied for the Documents List. That just causes confusion. And a possible Requirement for Improvement (RFI) in the Leadership chapter around lack of consistency of policies. That comes under LD.04.01.07 in both the Hospital and Behavioral Health manuals.

TJC has published an FAQ addressing the question of electronic vs. paper documentation. It also addresses the need to produce documentation timely when a surveyor requests it. It states that if there’s a “consistent pattern where requested documents are not readily available” there may be a RFI under the Leadership chapter (LD.04.01.05) in addition to an RFI for the missing documentation.

The take-away here is it’s critical to produce a document when a surveyor requests it. There’s nothing more frustrating to a surveyor than having to repeatedly request a policy or other document.

Moreover, you can no longer use the post-survey Clarification process for a lack of documentation during the survey. TJC changed that in 2017. So, all the more reason to be “on your toes” during survey and produce the requested documents.

New Joint Commission Document Review for Life Safety & Environment of Care

Be aware there’s a new Life Safety & Environment of Care Document List and Review Tool effective for hospitals 1/1/21. It’s part of the change in survey process whereby TJC eliminated the previous Environment of Care session from the Hospital agenda. For details, see our recent post Joint Commission Environment of Care Review: Different in 2021.

Important Note: The Joint Commission Environment of Care session remains on the agenda for Behavioral Health organizations surveyed under the Behavioral Health Care & Human Services standards.

Barrins & Associates Consultation

We’re now conducting our Mock Surveys and Continuous Readiness Consultations both virtually and onsite. We’ve incorporated all the new 2021 standards and surveyor tools. As always, we’re prepared to support your ongoing compliance and survey readiness even in these challenging times.