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Have you heard about virtual Joint Commission surveys? TJC began conducting these a few months ago.

They’re been limited to hospitals applying for initial CMS deemed status and opioid treatment programs. They’ve just recently begun in other types of behavioral health programs. So, what does a virtual survey process look like?

Virtual Joint Commission Surveys

We recently got a very informative glimpse of what a virtual Joint Commission survey looks like for a psychiatric hospital. TJC shared the survey agenda with the Consultants Forum group. Then, a TJC hospital surveyor walked us through the agenda and how they conduct the survey in the virtual mode. So, let’s take a day-by-day look at the virtual survey.

Document Review

There’s a new approach for Document Review on virtual surveys. The organization must upload all required documents to SharePoint prior to the virtual survey.

Surveyors report this gives them much more time to thoroughly review the documents and plan tracers. As a result, your policies, plans, and other documents will get careful scrutiny. Much more than when surveyors had to rush through them the first morning of survey.

It’s likely that, in the future, this uploading of documents will make its way into regular onsite surveys – not just virtual surveys.

Virtual Survey Agenda for Psychiatric Hospitals

In the past, a typical onsite survey for a psychiatric hospital would be three days. The survey team would usually consist of a nurse, a psychiatrist, and Life Safety surveyor.

For the virtual Joint Commission survey, that agenda is spread over four days with one surveyor assigned to each day.

Day 1 is the RN. Day 2 is the MD. Day 3 is the Life Safety surveyor. Day 4 is the RN again. So, let’s take a look at the agenda for each day.

Virtual Survey: Day 1 (RN)

The RN surveyor spends the first hour or so planning with the hospital’s survey coordinator. This includes the following activities:

  • Providing a list of HR files for the Competency Review Session
  • Providing a list of Medical Staff files for the Credentialing & Privileging Session
  • Reviewing the current inpatient census
  • Providing a list of discharge records for review
  • Reviewing the seclusion/restraint log
  • Reviewing the transfer log
  • Selecting a patient for interview

Next, there’s an opening session for leadership. This is similar to the current opening session for onsite surveys.

Closed Record Review

By mid-morning, the RN does the Closed Record Review session. Some typical records are patients who’ve had a restraint or seclusion, high suicide risk, and transfers to the Emergency Room.

For closed record review, be aware: All the “B Tag” requirements that were formerly in Appendix AA still apply to psychiatric hospitals with deemed status. CMS moved those B Tag requirements into Appendix A and updated the State Operations Manual effective 2/21/20.

(For related background info, see our recent post New CMS Survey Process for Psychiatric Hospitals.)


In the afternoon, the RN conducts tracers. Typical tracers include high suicide risk, a patient treated for an infection, and a restraint or seclusion. The surveyor also completes a virtual tour of a patient room for ligature risks.

The tracers include a patient interview and a clinical staff interview. Surveyors do medical record reviews virtually via the hospital’s electronic health record – sometimes supplemented by paper documents. (Paper records are still a challenge to be conquered!)

The last session on Day 1 is the Competence Assessment Session. It’s similar to the current onsite session. The surveyor reviews Human Resource files with hospital staff to determine if they meet the Joint Commission requirements for orientation, training, license verification, etc.

Virtual Survey: Day 2 (MD)

On Day 2, the physician surveyor does a Medication Processes System Tracer. This includes observing a medication pass in the med room.

The MD surveyor also reviews how the Pharmacy & Therapeutics Committee functions. Specifically, does it evaluate medication management processes across the hospital? And make improvements where needed?

Next, the MD surveyor conducts patient tracers – often on medically compromised patients or patients on high risk medications. In addition, there’s a new Admission/Triage tracer which includes an interview with Admissions staff.

There’s a Credentialing/Privileging Session that’s similar to the current process. The MD surveyor also does the Contracts Review Session. This focuses on clinical contracts; specifically, how leadership reviews the contractors’ performance against established performance indicators.

Lastly, the MD will often do some additional closed medical record review.  Frequently, this includes a death record and/or a medical transfer.

Virtual Survey: Day 3 (Life Safety Surveyor)

On Day 3, the Life Safety surveyor reviews with the organization all the required Life Safety and Environment of Care documents uploaded to SharePoint. He also conducts the Life Safety Building Tour with the help of a camera and a laptop. In addition, there’s an Emergency Management session with a focus on the organization’s response to theCOVID-19 pandemic.

For a glimpse into this process, see the American Society for Healthcare Engineering (ASHE) article on virtual surveys.

Virtual Survey: Day 4 (RN)

On Day 4, the RN surveyor returns. She conducts a combined Infection Control and Data System Tracer.

This combined approach is a new twist but, as always, surveyors have their own styles. Thus, some may choose to have these as two distinct sessions.

Whichever way it’s done, be aware that a major focus will be on your COVID-19 response. Specifically, how you adapted your IC policies and procedures to deal with COVID-19. Additionally, how you’ve modified your IC Risk Assessment and IC Plan to incorporate what you learned from your COVID experience.

For more on this topic, see our recent post Joint Commission Surveys: Infection Control Focus.

The RN surveyor also does a “Kitchen Tracer.” This includes an interview with the Dietary Manager and/or the Head Dietician. It typically also includes a clinical tracer on a patient with special nutritional needs.

The virtual survey wraps up with additional record review (if needed) and an exit briefing with the leadership team. Initial feedback on the virtual survey process has been quite positive – both from the surveyors and the organizations.

Regular Onsite Joint Commission Surveys

As more counties throughout the country begin to move into the Low Risk COVID category, TJC is working on scheduling regular onsite triennial surveys. As these resume, Our Mock Surveys and Continuous Readiness Consultations will help you get back up to speed and prepare for that next survey – whenever it occurs.