First in our series on TJC Survey Management Strategies

“You don’t get a second chance to make a first impression.” We’ve all heard that. You can be sure it applies to your Joint Commission survey. And certainly to the TJC Document Review Session.

You know the drill. The surveyors arrive at your facility. After introductions, their first real task is the Document Review.

How smoothly that session goes clearly sets the tone for your entire survey. And, be aware TJC tells surveyors that if documents are not ready they should start tracer activity.

Documents List

Essentially, the TJC Document Review Session is an open book test. TJC publishes the Documents List for the Hospital Program and the Behavioral Healthcare Program in its Survey Activity Guide. The SAG is available on your TJC extranet site.

The Hospital Documents List is lengthy (57 items.) The Behavioral Healthcare list is much shorter (11 items.) Either way, you must have every document on that list ready for surveyors that first morning.

Organizing the TJC Document Review Session

The key to a smooth Document Review is a well-organized set of documents. No surprise there!

Your goal? Make it easy for surveyors to find what they need. So, here’s some basic tips for a foolproof TJC Document Review Session:

• Organize the documents in a 3 ring binder with tabs. This way, surveyors can split up the documents that each one needs to review.
• Clearly label each tab. Use the same terminology that TJC uses on its Documents List.
• Provide a Table of Contents for easy reference.
• Be sure to include the most recent version of all policies.
• Be vigilant about policies given to surveyors at the program/unit level. Make sure they match what you have in your Documents binder.
• If a required document is included in minutes, label that particular set of minutes. Don’t make the surveyor go hunting through months of minutes.
• Regarding committee minutes: Make sure that attendees at subsequent survey sessions (like Infection Control) have read the minutes you provided to the surveyor in the Document Review Session. Surveyors often ask questions regarding things they’ve read about in the minutes.
• Don’t leave any tabs in the binder empty. (Yes, we’ve actually seen this.)

Additional Documents

Be aware: Even though there’s a published Documents List, surveyors can ask for additional documents. It happens all the time.

So, be prepared to produce documents as requested throughout your survey.  When we do mock surveys, we have a list of “also frequently requested” documents that surveyors often ask for.

Here’s an example. Surveyors frequently ask for the Informed Consent policy. That’s not on the Documents List. However, they often review informed consent for psychotropic meds during tracers. At that point, they’ll probably ask for your policy. They want to see how you’ve designed your informed consent process. And then they’ll survey against your policy.

Another heads up! If you show a pattern of not having documents readily available during survey, you may receive a finding under the Leadership chapter. See the FAQ on Records and Documentation – Format/Availability.

Recent Additions to TJC Documents List

In 2018, TJC added several new Emergency Management documents to the Documents List. For more background, see the TJC announcement Updates to Emergency Management Standards.

In 2019, there was only one addition to the Documents List for both Hospitals and Behavioral Healthcare programs. That’s the data on results of your evaluation of the Culture of Safety. An action plan to address these results is not listed but be sure to have that ready as well. (See our article Evaluating your Culture of Safety)

TJC Document Review: Behind Closed Doors

So, what goes on during the Document Review? Surveyors use this session for several purposes. First, simply to confirm that you have a required policy (such as organ procurement.)

Second, to gather information for upcoming sessions. For example, the nurse surveyor will review your infection Control annual evaluation and IC risk assessment.  Then, she’ll discuss these with you in the Infection Control tracer.

Lastly, to understand your hospital-specific policy so they can survey against it. Example: If your Fall Risk Assessment policy says you’ll reassess for fall risk every shift, they’ll look for that in the records. So, be clear about what you’ve committed yourself to in your policies.

As one Survey Coordinator related: “We didn’t realize our Medication Ordering Policy required an indication for use for every med ordered. Our practice is to do that only for PRN’s. But there it was in our policy. And we weren’t doing it. As a result, we were cited for it.”   

Benefit of a Strong Start

Once you’ve accomplished a smooth TJC Document Review session, you’re off to a strong start. Surveyors see you’re well organized and haven’t wasted their time. Thanks to that, they’ve gotten the information they need. Now they’re ready to see your patient care in action. You’ve set the stage for a smooth and successful survey!

Stay tuned for next month’s Survey Management Strategy on the Medication Management Tracer!