Some of our clients are “back in the saddle again” in terms of onsite Joint Commission surveys. For example, we had several clients undergo their onsite triennial surveys last month.
So, what are surveys like these days in light of the COVID-19 reality? We got some feedback from the field on recent survey developments.
Focus on COVID-19
In the words of one Quality Director:
“Right from the get-go, the Joint Commission surveyors were very interested in our COVID-19 response. That started in the leadership session on the first day.
They wanted to know what procedures we implemented to deal with potential COVID patients and also protect our staff. That was a lengthy discussion in our leadership session.
Similarly, that theme continued into the Environment of Care/Emergency Management session. The surveyor wanted to know if we had evaluated our COVID-19 response. Most importantly, what did we learn from it?
Fortunately, our Environment of Care Committee had written up a formal evaluation of our COVID response. It included what had gone well – and not so well – and what we learned from the experience.
The surveyors were impressed with that exercise. And we were very glad we had gone to the trouble of documenting our critique!”
For more guidance on emergency management exercises, see the recent CMS Memo QSO-20-41 Emergency Preparedness Testing Exemption and Guidance.
Also, TJC has issued guidance on the scoring of certain Environment of Care requirements for inspection, testing, and maintenance of equipment and utilities as surveys resume. Be sure to check that out so you’re clear on how the compliance scoring works.
Joint Commission Survey Tracers
Our clients report that tracers in these recent surveys focused on familiar topics. Typical tracers included suicide risk, restraint, patients on high risk meds, and patients with nutritional issues. There were also tracers on suspected COVID patients and patients with other types of infections.
Major Focus on Suicide Risk
Clients report that, during these recent surveys, the strong focus on suicide risk assessment continues. Most importantly, it’s not just the suicide risk assessment piece. It’s having a solid treatment plan and interventions that focus on the patient’s level of risk.
As one Clinical Director reported: “We’re using an evidence based tool – the C-SSRS. However, that wasn’t enough.
The surveyors zeroed in on how we were treating patients with a high suicide risk. They found several cases where we rated the risk level as high but the interventions didn’t match up with that level of risk.
Consequently, they scored that as High Risk and Widespread on the SAFER matrix. As a result, fixing that process is a high priority for us right now.”
As we know, deficiencies for suicide risk assessment are a frequent finding in behavioral health settings. For more insight on this topic, see our recent posts:
- NPSG 15 Suicide Risk Reduction: Feedback from the Field
- NPSG.15.01.01 Suicide Risk Reduction: Monitoring High Risk Patients
- NPSG 15 Suicide Risk Reduction: Safety Planning at Discharge
Some clients were surprised by the survey focus on the kitchen. “I’ve never had a surveyor spend so much time in the kitchen” said one Survey Coordinator.
The kitchen tracer has now become a routine part of Joint Commission surveys. For more on that topic, see our see our post TJC Tracer Update: Focus on Dietary Services.
Clients unanimously reported the Joint Commission surveyors strictly adhered to CDC guidelines for minimizing spread of COVID-19. They wore masks and kept socially distant during meetings. In addition, they kept meetings to small groups and used videoconferencing to add attendees.
For full details on how TJC is handling resuming surveys, see their Clarification on Resumption of Survey and Review Activities published July 1, 2020.
Barrins & Associates Mock Surveys
As we resume our Mock Surveys and Continuous Readiness Consultations in full force, we’re covering all these most recent updates to the Joint Commission survey process. That way, you’re prepared and confident to put your best foot forward come survey time!