The Document Review session has always been a component of TJC surveys. Years ago, it meant the surveyors spent hours poring over documents and, consequently, less time out visiting programs and units. Once the tracer methodology came along, that emphasis shifted (thankfully) and now surveyors spend more time doing tracers and less time on Document Review. However, the materials that are assembled for the Document Review remain important for two reasons. First, they are the first impression that surveyors get about your organization’s readiness for survey. Second, they provide key information to the surveyors about your compliance with TJC requirements. Indeed, surveyors are sometimes scoring compliance with the standards during the Document Review session based on issues they have identified in policies, plans, and minutes.
The Documents List for both Behavioral Health Programs and Hospitals is included in the TJC Survey Activity Guide on your TJC extranet site. The list for BH programs is relatively short and includes ten items. The list for hospitals is much longer. It includes 44 items and now contains many CMS requirements.
It’s important to keep in mind that documents, policies and other information not included on the Document Review list may be requested throughout the survey. It’s not unusual, in our experience, for surveyors to ask for a policy as they are out doing a tracer and come upon an issue that they want to pursue further. It’s also important to be aware that there are specific standards that require policies (i.e. written policies) and that some of these required policies may not be included on the TJC Documents List.
With this in mind, we have expanded the Documents List that we use when conducting mock surveys for our clients. It now includes not only the items listed in the TJC Survey Activity Guide but also items that we have seen frequently requested by TJC surveyors over the years. In addition, the Barrins & Associates Documents List references the TJC standard and element of performance (EP) related to each item on the list. That way, you can, if needed, look up the standard and EP to see exactly what the requirement is and what type of documentation TJC requires. For example, one item on our Documents List for hospitals is the Infection Control annual evaluation (IC.03.01.01 EP 1 – 7). When you look up that standard, you will see the specific requirements for what the IC annual evaluation needs to include.
We have a Documents List for Psychiatric Hospitals and a Documents List for Behavioral Health Organizations. We are pleased to share those with our readers to support your TJC readiness efforts.
Lastly, a couple of tips related to preparation of documents and policies: Make sure that the documents for Day 1 are well organized (clearly labeled, tabbed, etc.) and easy for surveyors to review. If additional documents such as specific policies are requested during the survey, make sure that the surveyors receive the correct and most recently updated version of that policy. We have seen many occasions where a well-meaning manager hands a policy to a surveyor that is not current and perhaps not in compliance with the standards. Typically, this eventually gets corrected by the Survey Coordinator but not before some confusion and misunderstanding have occurred and who needs that? Just like in life, it’s the little things that count during a survey!