Heads Up! Recently, several of our clients had their unannounced TJC surveys earlier than they anticipated. That includes both psychiatric hospitals and behavioral health organizations.
So, is this a trend? Hard to tell but best to be prepared in case you encounter this situation.
TJC’s official policy is that they “conduct unannounced surveys unless it is not feasible or logical to do so.” Also, all hospital surveys (including deemed status surveys) are unannounced.
Exceptions to Unannounced Surveys
There are some exceptions to unannounced surveys. These include:
First Surveys: The first survey that TJC conducts of an organization is announced unless that survey is for deemed status purposes. Having said that, we know TJC works closely with psychiatric hospitals on their first deemed status survey. They try to schedule it soon after the hospital admits the required number of patients.
Behavioral Health Organizations: Surveys are announced for correctional settings, foster care programs, and freestanding methadone programs. In addition, if the BH organization has less than ten staff or an average daily census of less than 100 and meets any of the following criteria, their survey is announced:
- “Small” settings
- Outpatient/day programs
- 24 hour services
- In-home Behavioral Health
- Case management
- Assertive Community Treatment (ACT) programs
- Inpatient freestanding organizations
- Community based freestanding organizations
- Inpatient crisis stabilization programs
- Residential/group homes
Thus, given this fairly lengthy list of exceptions to unannounced surveys, the majority of BH surveys are announced. This means TJC gives seven days’ notice of the survey.
The Survey Window
The official survey window for your triennial survey is anytime from 18 to 36 months after your last full survey. So, why might TJC survey you on the earlier end of that window?
One reason is if you’ve been in Preliminary Denial of Accreditation (PDA.) In that case, you should anticipate TJC may survey you early in that window.
Another reason could be you’ve added services since your last survey and TJC chose not to do an extension survey. Instead, they may schedule your triennial survey a bit early and include those new services.
At the same time, we’ve seen organizations have “early surveys” even when neither of these two factors played a role. So, unfortunately, it’s tough to predict.
Unannounced Surveys: Mobile Phone Notification
Did you know you can use your smart phone to check and see if TJC will be surveying you that day? There’s a mobile-friendly version of the Notification of Scheduled Events that will tell you if TJC has scheduled you for a survey that day. They post this notice by 7:30 a.m. on the day of your survey. You can also see the info about your surveyors.
“Early Survey” or not, the best way to get off to a strong start is with a well-prepared Document Review session on Day 1. Therefore, that means well-organized polices, minutes, and plans that are easy for the surveyors to review.
For detailed advice on how to prepare for this session, see our post TJC Document Review Session: Survey Management Strategies. Also, remember that TJC added one important document to their 2019 Documents List in their official Survey Activity Guide. That’s the evaluation of your Culture of Safety and your Action Plan. For more on this, see our post Evaluating your Culture of Safety.
Survey Readiness on the Front Line
The other strategy that’s critical for a strong start is making sure to alert your units and programs that the survey is about to commence. This is when your Communication Plan should kick into action. Most importantly, those programs should have clear instructions about any last-minute survey preparation they need to do.
Above all, Continuous Readiness is the key to survey success when an “early survey” strikes. We heard this recently from one of our clients. “TJC came five months ahead of our 3-year anniversary date. What a shock! Luckily, the Barrins team had just recently done our annual mock survey. Thanks to that, we were very well prepared and had a smooth survey and an excellent outcome.”