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Surprise Joint Commission Survey: What You Need to Know

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The Joint Commission is the nation’s oldest and largest health care accrediting body, currently accrediting and certifying more than 22,000 health care facilities and programs. It seeks to continually provide the guidance and regulations to ensure health care is safe, effective and the highest quality for the public.

On March 16, 2020, The Joint Commission, suspended all regular, on-site surveys amid the COVID-19 outbreak. At the time, the decision was made to allow health care facilities and professionals to prepare for the influx of COVID-19 patients and focus on their care. A year in and The Joint Commission is starting to conduct unannounced in-person visits again. 

Unannounced! But Why?

Let us take a step back and explain why The Joint Commission conducts unannounced surveys. There are four reasons these unannounced surveys are conducted:  

  1. Help health care facilities focus on providing patients safe and quality care.  
  2. For The Joint Commission and its accredited organizations to affirm the expectations of continuous standards compliance. 
  3. Ensure credibility in the accreditation process is not lost by observing organizations in their natural working conditions. 
  4. On behalf of the health care organizations, reduce the unnecessary costs related to survey preparation. 

An unannounced survey will typically occur 18 – 36 months after the previous survey. This timing is determined by certain criteria, data, and other factors. Hospitals, Medicare centers, and Medicaid Services are all recipients of unannounced surveys. There are a few health care programs that are exempt from unannounced surveys, including: 

  • Ambulatory care 
  • Behavioral health care 
  • Disease-specific care certification 
  • Health care staffing certification 
  • Home care 
  • Laboratory 
  • Medicare/Medicaid certification-based long-term care 
  • Department of Defense 
  • Bureau of Prison 
  • Immigrant facilities 

Prepare for the Unexpected

It is near impossible to know when the Joint Commission will show up. There is really only one sure way to be as best prepared as possible: maintain and go above and beyond the Joint Commission’s standards. Doing the bare minimum may get you accreditation, but with the off-chance the Commission’s standards may change due to an ever-evolving health care industry, going above and beyond is the safe place to be. The Commission’s standards change as they identify areas where improvements in the health care industry should be made to better serve patients. You can find recent changes under the “What’s New” section of the All Accreditation Programs Survey Activity Guide 2021. This guide is also a great resource to keep on hand as it includes inspection process details, documents you should have prepared, and a health and safety checklist.  

While preparing the documents and going through the checklist helps, it’s also critical to train and prepare staff on HIPPA compliance, emergency preparedness, and more. The surveyors will ask many questions related to these topics, along with patient care.  

Now's the Time to Shine

Your health care organization can do everything it can to prepare for the Joint Commission’s survey. It is likely people will be anxious. All documents and training have been checked off. What is left? These five tips can help improve your chances of a successful survey.  

  1. Identify standard changes and correct current practices. 
    1. It can be a daunting task to thumb through the whole Survey Activity Guide, but it will be worth if there are critical changes that your accreditation may depend on. If possible, correct these changes prior to an accreditation survey.  
  2. Do not make the same mistake another organization made. 
    1. Learn from others. Each year around the same time, The Joint Commission publishes a list of common items that failed inspections. View these as another checklist. Take the time to review and ensure that your organization is up to standard.  
  3. Clean the hallways.
    1. You do not want random items in your way at home, so do not have the same in the corridors of the health care facility. Less clutter is better. This can delay emergency response, cause injuries, or even fail a survey. Surveyors understand that some emergency equipment needs to be kept in the hallway, but limit what’s necessary and not.  
  4. First impression is everything.
    1. This goes for all industries, but when it comes to The Joint Commission and surveys, it is important for everyone to be on the same page in terms of greeting, hosting, and touring.  
  5. Know the news.
    1. With anything, it is important to stay up to date on key pieces of news and information. Same goes for The Joint Commission survey. It shows you are well-versed in the key topics, including workplace items, and know what’s happening around the industry. 

Going above and beyond will help ensure that The Joint Commission survey will be successful. It is important to stay up to date on the latest survey changes and implement accordingly. The Joint Commission survey visit can be a nerve-wracking experience, but do not let it get the best of you. By following the tips addressed above, you will surely be on the road to success when the surveyor arrives unexpectedly.  

Tags: life safety, fire safety, compliance, inspections, #jointcommission, #healthcare