The Surveyors are Here, Now What?

Success Strategies for the Survey

1

Success is an Ongoing Activity

• Managing the non-survey years• Managing the onsite survey process• Several roads to onsite survey trouble• After the survey – when to clarify• Top scored problem areas

2

Benefits of Accreditation

• Why do we put ourselves through this?– Yes, you really are better than non accredited

hospitals

• The process involves state of the art, peer developed standards and safety goals

• Participation helps create a better, safer environment

• The on site survey validates your hard work.

3

Managing the Non-Survey Years

• Keep policies simple• Mock Tracers to check compliance• If you are in a whole stop digging (fix it or find

another way)• Focus on the top 10 and new things• Avoid the Situational Rules (quick trip to PDA)

4

What You Can Be Scored On

• The Elements of Performance/Standards• Situational rules in manual• The Frequently Asked Questions • Information found in Perspectives• Your own policies

5

FIX IT OR FIND ANOTHER WAY

• Einstein on insanity – “Doing the same thing over and over again and expecting different results.”

• If your self evaluation finds failure with this expectation month after month, it isn’t going to get better before survey

• TJC’s specific requirements can become steps in your processes

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04/20/23 7

MANAGING THE NON SURVEY YEARS

• Maintain the momentum• Stay in contact with your account rep• Access the extranet regularly• Read and distribute Perspectives monthly• Remember, your next survey may not be in the

year due

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MANAGING THE NON SURVEY YEARS• Track the PFI progress and request an extension

if needed• Make sure ancillary departments have their

licenses and fulfill accreditation requirements.• Implement the new stuff as soon as published• Assume nothing, rely on data to self assess• Consider smart phone or tablet applications for tracer

teams to capture, photo, fix and track compliance. (iAuditor, AuditBee, Comply Flow Audit)

Focus on the Top 10 & NPSGs

• The 2012 standards have 1700 EPs that can be scored

• The Joint Commission does >90% of its scoring on about 25 standards/NPSGs

• Implement the top scored and all NPSGs• Spend you dollar here!

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DESIGN FORMS FOR ENHANCED COMPLIANCE

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Consent Obtained

... Other text …

Signed: ____________ MD

... Other text … Consent obtained.

Signed: ____________ MD

H and P Updated

... Other text …

Signed: ____________ MD

... I have examined the patient, reviewed the findings of the history and physical and any changes are specified as follows: ______________________________.

Signed: ____________ MD

Pre-induction assessment conducted.

Identify natural components of the pre-anesthesia evaluation.

Preparing for Successful Surprise-Free Survey

• Get all the day 1 and LSC documents together, print draft agenda *1

• Read the SAG• Look for problems in the unlikely spots,

UP in procedure areas not main OR, unlabeled syringes in procedure rooms.

• Train and practice with staff and escorts on successful survey interview tips

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Success During the SurveyManaging the Onsite Survey

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GOOD MORNING, WE ARE HERE FROM THE JOINT COMMISSION

• Have an action plan *2• Institute the action plan• Have identified back up staff• Verify ID via extranet• Rolling carts with required information• Optional information shows great things

only

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They’re Here!A Well Planned Calling Tree

• Have a call list with back-ups and double back-ups for key roles

• Staff invited to system tracers should get notice as to the time and location of these with reminder as to which documents to bring

• Have back-up for the 7:30 am TJC web check

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Have Your Binders Ready

• One for the surveyor team• A different/more detailed one for staff• Recommend individual surveyor folders

15

Meet & Greet, They are at the Door

• First impressions are important• Have ground crew act as scouts for team arrival,

not joking!• Front line staff greet and seat.• Get their IDs, compare to your photo from TJC• Issue IDs• Walk them to their room, • Present them with day one binders• Get leaders ready for opening conference

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Other Day One Action Items

• Reserve conference rooms• One for surveyors, one for staff and all

meetings• Get catering• Print and distribute agenda (found on

extranet under pre-survey documents)• Invite system tracer attendees• Identify any necessary agenda changes

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Opening Conference

• Slide set or no slide set??? – Have a prepared short slide set– Print and place in each surveyor folder– Be prepared to do the opening with and

without the projector, may just want casual talking

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Opening Presentation

• Basics of who you are, size, services• Mission, vision, goals• Bragging Rights - Special awards,

certifications • Sob stories - how do you address a

potential big risk area?• Community you serve• Some PI or patient satisfaction data

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Day One Binders

• There are two TJC day one lists– The list from the Survey Activity Guide (SAG)– The surveyor list, PRN items

• Have the Day One SAG list ready – give to surveyor

• Have the PRN list in your hands, give only what is requested specifically

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Tips

• Avoid showcasing dirty laundry– Have fresh eyes look through every thing in

the day one material and other material given to surveyors

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Send “Checklist” to All Unit Managers

• Each manager to print or pull punch list from their TJC folder, give location specific list to staff to review: *3– Medication room– Hallways and nurses station– Clean utility– Dirty utility

• Each list is specific to their area, check everything, initial, call in work orders

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Escorts, the Power Player!

• Assign escort and note taker *4• Never leave the surveyor alone• Eyes and ears for your leadership• You are the early warning system; text the

next unit when the surveyor is on the way• Be adept at the computer

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Role of the Escort/Note Taker

• With an electronic system consider a buddy system, have someone other than the nurse search the record for requested information

• Gently coach• Record offers to present support and record

surveyor’s response• Record the “he said” “she said” • Record MR numbers

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On the Unit, all Hands on Deck• When surveyor is on the way, assemble your

team• Meet the surveyor at the entrance to unit,

escort them • Find a clean room for them to review charts• Get your team, include pharmacy, nurse

educator, Respiratory Therapy, case workers, (have them up and “working” on unit

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Institute the Action Plan, Everyone in Position

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When They Are on the Unit

• Know where to find your policies & “fast facts” or other tip tool *5

• Have two people in the patient record, a second person as back up looking for stuff

• Offer policies, describe education• Use your resources, you don’t need to

memorize• Call on experts around you

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When They Leave Your Unit

• After the team leaves, find all “IOUs”• Find the order• Find the anesthesia record, the consent, etc• Copy it, highlight the part the surveyor couldn’t

find• Find the surveyor, show them AND/OR• Bring a copy to the surveyor room during special

issue resolution, escort should record this

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Help Staff by Conducting Internal Tracers:

• Train staff on what to expect during the survey

• Ask yourself, ask your staff:– Do we do this?– Where is it written we do this?– How well, or how often do we do this?– Show me the evidence that we do this– Validate the “doing” with high risk and high

priority standards

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Tracer Tips For Staff• Be enthusiastic about how good we are• Focus on the excellent service and care we provide• Find a quiet room, out of main traffic path to review the

medical record for the patient tracer• Before answering a question:

– Take a deep breath– Make sure you understand the question– Or ask “Could you please rephrase that question…”– Stop talking once you have answered– Know where policies are kept & how to access them

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Tracer Tips For Staff

• Training – practice tracers• Never, never “fix” a chart to avoid an RFI• Don’t allow yourself to be intimidated by

surveyors, or by your own management. Stay calm if possible.

• If you do not know the answer to a question, describe how you would find the answer, who has the answer, and/or offer to provide the answer later in the day

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Tracer Tips For Staff• Take advantage of surveyor suggestions• Never “make up” answers to please the surveyor• Do not argue with the surveyor• Know what improvements in patient care came

from PI (performance improvement) activities• Describe your continuous compliance in an

environment of improvement• Don’t affirm the leading question…” this isn’t a very

good process, is it?”

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•It is the Joint Commission equivalent of the “go directly to jail” card!

•Joint Commission believes there is substantial noncompliance issues that have caused or could cause harm/death to patients or staff. •ITL called, your accreditation status changes to Preliminary Denial of Accreditation (PDA) overnight!

Trouble OnsiteImmediate Threat to Life Immediate

Threat

“Situational” Decision Rules

Direct Impact

Indirect Impact

How Bad Can It Be?Immediate Threat to Life

• The surveyors survey protocol guide for immediate threat states: "Failure to follow pertinent guidelines from APIC, CDC, WHO, etc."

• Requires the surveyor to consult with the Joint Commission field director, who consult with VP’s and EVP’s

• Can only be approved by President of Joint Commission

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•EC & LS examples from Perspectives, conferences, other communications:

– One single issue or a combination of observations:

– Inoperable fire alarm system– Inoperable or unreliable fire

pump– Inoperable Medical Gas System

or alarms– Negative pressure rooms not

working– Generator tests failed, not fixed

Immediate Threat to Life

Immediate

Threat“Situationa

l” Decision

Rules

Direct Impact

Indirect Impact

3

2

•EC & LS examples cont:– Utility system: main circuit

breaker not tested or maintained

– Raw sewage leaking from pipes in basement

– No way to transmit fire alarm signal to local fire department

– No emergency exit and no ILSM to compensate

Immediate Threat to Life

Immediate

Threat“Situationa

l” Decision

Rules

Direct Impact

Indirect Impact

3

2

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Leadership action plan:

◦ All hands on deck quickly! ◦ Get the facts, copies◦ Involve your leadership◦ Clarify with the surveyor◦ The phone call from Joint Commission leadership

is your best time to prevent ITL… be prepared to coherently explain why patients were not in jeopardy if you get “the call”

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After the Survey

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Post Survey

• Clarify everything even if you are not adverse– Random Unannounced Validation (RUV)

surveys - 5%– RUVs will review ESC and MOS onsite– RFIs add to S3 point total, may be used to

shorten time until next full survey• Keep records of ESC & MOS (RUV)

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Clarification

• Evidence that the organization was compliant with the element of performance at the time of survey– We found it, here it is– We audited and are compliant 90% of the

time• Corrective actions do not count in your

favor

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04/20/23 41

MANAGING THE POST SURVEY PROCESS

• Understand you’re A,+ C’s• Use audits for C’s and look for the

documentation about missed A’s. • The performance observation may be

totally correct, but you still have audit opportunities.

• Remember 2 observations is very sensitive compared to 90%.

Lessons Learned from Recent TJC Surveys

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Strategies for SuccessPreparing Clinical Areas

• Rollout the Clinical Area Checklists– Email them out, assign, implement, collect

them back, analyze compliance

• Involve/educate clinical & frontline staff • Everyone knows who to call to get fixed• Identify areas to improve, fix it, then

reassess• Make LS an every day expectation!

Environment of Care10 easy fixes

• No equipment blocking • fire alarm pull boxes, • fire extinguishers, • electric breaker panels, • medical gas shut-off valve boxes.

• No blocking fire doors, • No storage in stair wells

Environment of Care10 easy fixes

• Keep hallways clear of clutter• Fix broken locks and hardware • Fix large gaps under doors or at door

closures• Fire rating label on doors should be

visible• Doors that don’t self close properly,

door wedges!

Environment of Care10 easy fixes

• Unclear, or missing or unmarked fire exits, exit lights that are burnt out

• Fire extinguisher checks, safely stored• Label and secure hazardous areas• 18 inch rule for sprinklers• Sprinkler pipes can not support other items like

cables or wires• Sprinkler head clean and free of obstruction, collar

flush• Remove or repair nasty things: Ripped mattresses,

cracked ceiling tile, mold, broken wheel chair

Environment of Care10 easy fixes

• Medical Gas shut off valves must be labeled with rooms they shut off. Staff must know who can shut these off and when. Alarms working

• No unsecured O2 tanks, no storing too many

H&P and Update • An H&P is done no more than 30 days prior to

admission or within 24 hours of admission. • If the H&P is done anytime in the 30 days prior to

admission you update it within 24 hours of admission, or prior to an invasive procedure on the day of the procedure, whichever comes first.– Must document: the patient was examined, and the H&P

was reviewed - CMS mandate– In EMR – use a SmartText: e.g., .no changes or .changes

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Document Operative & High Risk Procedures (RC.02.01.03)

H&P in record before procedure (EP 3) Post op/post procedure report is dictated

before transfer to next level (EP 5) (Unless a post op/post procedure note is

entered immediately [see EP 7], if so, report may be written or dictated per policy)

The post operative/procedure report includes: name of LIPs, procedure name and description, findings, EBL, specimens, post op diagnosis (EP 6 - Top Scorer)

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Document Operative & High Risk Procedures (RC.02.01.03)

If report is delayed, an immediate post procedure note is entered and includes LIP, assistants, procedure(s) performed and finding(s), ANY EBL, ANY specimens, Post op diagnosis (EP 7 top scorer). Check your policy.

Medical record includes the LIP release order or approved DC criteria (EP 9)

Medical record includes the use of DC criteria/pt readiness (EP10)

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Medication Orders

• Preprocedure meds and testing by protocol is now permitted with qualifications

• Cannot sign post-operative anesthesia or surgical orders pre-operatively

• Got away with it on paper; could fudge or omit the time and not be noticed

• CPOE captures the time automatically• Must pend and go back in and sign

Medication Orders

• Intraprocedure verbal orders need to be countersigned by LIP

• On paper – sign the OR flow sheet/ MAR• eFlow Sheet or eMAR and goes to LIP inbox

for electronic signature

Medication/Fluid Integrity

• IV bag fluids and Irrigation bottle fluids• Cannot exceed 104 degrees F, check

manufacturer• Wise to record a daily temp reading• IV bag in outer pouch: 14 days,

– label with new, “do not use beyond” date

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Label All Medications(NPSG.03.04.01)

Label all meds on and off the sterile field.• All products, including sterile water/saline,

disinfectants in a basin must be labeled.• The safety goal includes bedside procedures as

well as IR, cath lab, Out Patient• Its an A element of performance

Time Out (UP.01.03.01)

The final verification process must be conducted in the location where the procedure will be done, just before starting the procedure

Cath, Endo, ASC, AMB, IR, bedside, etc.Compare two identifiers on the arm band (if

visible) against the medical record, OR select one of the following three options…

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Time Out and 2 identifiersThree Options

• Two team members confirm patient ID upon arrival in the procedure suite using two identifiers.

• One of the two team members remains with the patient during the entire pre-procedure process.

• During the final time out, this team member confirms patient ID. OR• Two team members ID patient upon arrival in procedure suite as previously

described. • Two patient identifiers are written on white board in procedure room and

confirmed by the two team members. • During final time out, the team confirms patient ID against information on

white board. OR• Place a patient ID on an exposed extremity – alternate wrist or either ankle. • Reference the two identifiers on this ID band during the final time out.

Reduce Risk of Infection

• Surveyors will observe staff as they process dirty equipment

• Surveyors will check manufacturer instructions for use (IFU) for three things: the device/instrument, the sterilizer itself, and the packaging (i.e., blue wrap or flash pan.)

• Check your policy, check staff understand and follow both. Create a recipe book

• Will observe proper use of PPE

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Laryngoscope Blades• Clean and (at least) high level disinfect them per

manufacturer instructions for use• Store in manner that prevents recontamination• One blade per Zip-Lock bag if HLD, or • Peal pouch if steam• Consistent practice throughout the hospital• Testing light source?

– Hand hygiene and/or use gloves– Place back into Zip-lock bag or peal pouch– Battery expiration dates!

High Level Disinfection - Scopes

• Follow manufacture recommendations• E.g., glutaraldehyde or OPA test strips

– Date when opened– QC run on a positive and negative solution– Requires 6 strips right from the start– Document the strip QC– Testing prior to each load, document QC

Separation of Clean/Dirty

• Scrutiny of scope cleaning room to determine if flow/practice prevents cross-contamination

• Key: remove HLD scopes from sterilizer only when no other dirty scopes are in the room

• Flawless QC and load record documentation• Proper PPE

Scope Storage

• Hang in a positive pressure vented cabinet• Avoid tip dragging on base (avoid rack sag)• Avoid cross-contamination (adjacent sink??)• 30 day shelf life? (August 2011 OR Manager)• Never store in foam mold in hard case

Consistent Practice

• How many TEE probes exist in the hospital?• How many nasogastric scopes? Where???• In each area – are decontamination, testing,

QC, HLD processing, load record-keeping steps performed consistently???

• Exact concentrations, soak times, handling• Inventoried by Biomed/Clinical Engineering

Sterile Processing Tour

• Attire: donned at the hospital, changed daily• Red line – no one enters without proper

attire• No artificial nails, nail polish, jewelry, watch• Head AND facial hair covered at all times• In Decontamination: liquid-resistant garb,

heavy-duty gloves, eye protections• WASH HANDS WHEN FINISHED

Immediate Use Sterilization• Important that staff can speak to the process without

using the term “flash”• Follow manufacturer recommendations for sterilizer,

pack, instruments, CI, BI• Covered containers even in sub-sterile• “A sterilized item intended for immediate use is not stored for

future use, nor held from one case to another.”• “Instrument inventories should be sufficient to meet anticipated

surgical volume and permit the time to complete all critical elements of reprocessing.”

• Submit data to PI Committee /leadership to justify purchase

SPD Facility

• Easily cleaned walls, floors and ceiling• Daily housekeeping• No exposed pipes, etc. that collect dust• Maintain neg/pos pressure by keeping doors and

windows closed; test pressures monthly• Sinks available for hand washing• Eye wash within 10 second travel time; single action

lever, tepid water temperature to allow 15 minute flush time

Temperature, Humidity, Storage

• Monitor and record daily• Temp 68-73 in clean area of department• Temp 60-65 in decontamination • Humidity 30-60% in work areas• Humidity not > than 70% in sterile storage• 18 inch, 6 inch, 2 inch, solid lower shelf

Loaner Equipment

• Clear policy and procedure, penalties for noncompliance; ripe for short-cuts

• Mandate 48 hour lead-time???• Follow manufacture recommendations• Staff should blow whistle if uncertain

Tissue Management TS.03.01.01

– EP 1 Assign responsibility for tissue– EP 2 Policy for acquisition, receipt, storage, issuance– EP 3 Confirm FDA registration, have current paperwork– EP 4 Spread process throughout hospital– EP 5 Use manufacturer instructions for transporting,

handling, storing and using tissue (verify that vendor keeps records per lot # in event of RCA)

– EP 6 document receipt of tissue(TS.03.02.01 EPs 3 &6)– EP 7 at receipt, package integrity and temp control is

verified (TS.03.02.01 EP 6)

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TS.03.02.01

– EP 1 Bi-directional tracing including discarded (FAQ ‘10)– EP 2 Written materials/instructions to prepare or

process (FAQ TJC)– EP 3 date/time/name of staff involved at receipt/

acceptance, preparation, and issuance.

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Questions???• Kurt Patton

– Kurt@PattonHC.com

• Jennifer Cowel– JenCowel@PattonHC.com

• John Rosing– JohnRosing@PattonHC.com

• Mary Cesare Murphy– MCM@PattonHC.com