There’s a valuable resource you should know about on your TJC Connect extranet site. It’s the Joint Commission Heads-Up Report. You’ll find it under the Resources & Tools section.

Joint Commission Heads-Up Reports

TJC produces these reports quarterly for all accreditation programs. The reports identify specific standards surveyors have been citing on recent surveys.  In addition, they identify why the surveyors are citing these standards.

So, you get valuable information about survey trends across the country. Thus, the “heads-up” aspect:  you can use this information to identify potential compliance risks within your own organization. Let’s take a look at just what the Heads-Up Reports contain.

Joint Commission Survey Trends

TJC selects the topics for the Heads-Up Reports based on scoring data, surveyor findings, and input from Joint Commission subject matter experts. Their database now includes information from surveys conducted between January 1, 2018 through September 1, 2020.

The Joint Commission Heads-Up Reports provide the following data:

• The number of surveys that scored this requirement as non-compliant
• The specific standards and Elements of Performance cited
• The CMS Condition of Participation (CoP) that matches the Joint Commission standard

The reports also include de-identified surveyor comments that explain why they cited the standard as non-compliant. Clearly, that’s very valuable information. Essentially, you can use it to analyze whether there are similar non-compliance risks within your organization.

Examples of Joint Commission Heads-Up Reports

Here’s some examples of recent Heads-Up Reports for the Behavioral Health Accreditation Program and the Hospital Accreditation Program.

Behavioral Health Accreditation Program: Sample Heads-Up Report

• Topic: Credentialing and Competency Assessments (HRM.01.02.01 EP 1, HRM.01.06.01 EP 3)
• Time period: January 1, 2019 – March 31, 2020
• Number of full surveys performed: 1380
• # of surveys that scored this as Moderate or High Risk on the SAFER matrix: 193 (14%)

Plus, some sample findings from the surveyors on this topic:

There was a lack of or a delay in primary source verification for staff licensure. This was at either the time of hire, renewal or expiration. For example, the organization hired one staff member but did not complete credentialing until the following year.

The Human Resources Dept. indicated an initial assessment of competencies is part of the 90 day orientation process. However, there was no documentation of initial competency assessment for a staff member hired 6 months ago.

Competency evaluations that were present did not correlate to job descriptions or align with core responsibilities.

The Heads-Up Report goes on to identify contributing factors to this non-compliance. In addition, it includes recommendations on how to identify potential problems in your own organization related to this function.

Since 2019, the topics in the Behavioral Health Accreditation Program Heads-Up Reports are:

• Identifying trauma, abuse, neglect, or exploitation
• Nutritional screening
• Credentialing and competency assessment
• Identifying environmental suicide risks

On a related note, we’ve covered several of these topics in our posts and monthly newsletter:

• Trauma Assessment: Feedback from Recent Surveys
• Joint Commission Nutrition Screening Requirements for Behavioral Healthcare Programs
• Ligature Risks: New FAQs from TJC
• TJC Competence Assessment Session: Survey Management Strategies

Hospital Accreditation Program: Sample Heads-Up Report

• Topic: Safe Medication Administration (MM.06.01.01 EP 3)
• Time period: January 1, 2019 – December 31, 2019
• Number of full surveys performed: 1416
• # of surveys that scored this as Moderate or High Risk on the SAFER matrix: 317 (22%)

Sample findings from the surveyors:

A sliding scale insulin order indicated that 6 units of insulin should be given for a blood glucose of 258 on (date) at 1630. There was no documentation this insulin was given.

Surveyor reviewed record of patient on sliding scale Heparin. The incremental rate changes that were made based on serial aPTT results did not match the provider’s order.

Patient had an order for promethazine 25 mg PO or IV q 6 h prn n/v. Policy stated to administer oral before IV. The medical record revealed staff administered IV prior to oral.

Since 2019, the topics in the Hospital Accreditation Program Heads-Up Reports are:

• Safe medication administration
• Managing risks associated with utility systems
• Granting disaster privileges to volunteer LIPs

On a related note, be sure to also keep up with TJC’s recent FAQs on safe medication administration:

• Medication Administration – Range Orders
• Medication Administration – Incorporating Patient Preference into Medication Administration Practices
• Medication Administration – Titration Orders – Documenting During Rapid Titration
• Medication Administration – Therapeutic Duplication vs. Multimodal Therapy

Capitalizing on Joint Commission Heads-Up Reports

So, what’s the best way to utilize these Heads-Up Reports? We recommend you share these reports with the key stakeholders responsible for the various topic areas covered in the reports.

There’s nothing like reading a deficiency in an actual survey report to make one realize the surveyors could find a similar issue in your own organization.

We at Barrins & Associates maintain a similar database of our clients’ findings across the country. We’ve found sharing survey findings from other organizations to be very valuable.

Often, we hear reactions like “Wow, they (TJC) could find the same thing here…” In essence, it catches people’s attention and usually motivates them to get started on fixing the issue.

Barrins & Associates

As we resume our Mock Surveys and Continuous Readiness Consultations in full force, we’re covering all these recent topics and high focus areas. That way, you’re prepared and confident to put your best foot forward come survey time!