The Joint Commission Survey

After years of patient safety education the highlight of my work is being able to attend a Joint Commission survey. It helps patient safety come full circle while my focus stays on the patient outcomes but I can see things through the hospital policies and procedures.

As a Commissioner on the Joint Commission (also called a board member) I am one of 7 “public members”. I am not there as a representative of a healthcare organization such as the American Medical Association, American College of Surgeons or any one of the other prestigious groups who make up the governing body of the JC as it has been called since the change in name in 2008. As a public member, I am there as a patient, potential patient, family member of a patient or someone from the public with an interest and some knowledge (and passion helps) in patient safety.

To participate in surveys, commissioners observe the process so we can participate somewhat intelligently on the decisions being made at the board level. It also helps being a member of the Accreditation Committee. The Accreditation Committee is where discussions happen following a survey when there are outcomes that need addressing.

Each team of surveyors has someone in charge of the group. This is the Team Leader and basically set the tone, and run the survey. The team consists, usually, of a nurse, doctor an administrator and / or a life safety code specialist. The life safety code specialist specializes on the environment of care. This includes fire safety, engineering, electronics and much more as it pertains to the buildings safety.

The survey begins with a meeting in the lobby of the hospital before 8:00 AM. By this time, the facility staff had less than an hour to know of the team’s arrival. They are informed, by way of the internet that the surveyors will be there. They are given the teams names and some background on the website. At this point, either the organization is ready, or not. There is no planning that can happen now.

Generally greeted warmly, there is a sense of discomfort in the air as now these unannounced guests will be taking over offices, go through files and interview already overworked staff. Sometimes people get called in from vacation and soon all leadership begins to envelope the surrounding rooms ready to answer questions, assist in tours and retrieve files and books of information.

The courtesy shown by the surveyors are a clear example of their own knowledge of being on the receiving end of a Joint Commission survey. They too work in hospitals and have an understanding of the process from both sides.

As the surveyors get settled in, introduce themselves to each other, share some small talk about the facility and their past experience, the hospital staff is preparing in another room a meeting with all the department heads and senior level staff.

By 9:00 AM everyone is crowding into a large conference room. There can be as many as 15 – 20 senior leadership depending on the size of the facility. The team leader begins the introductions.

Once the group has shared pleasantries, the team leader will discuss why they are there and what they expect to see. The organization staff will give a history and overview of the facility. This will include their size, staff, accomplishments and the neighborhood they serve. The team will now go back to continue reading by-laws, hospital policies and reviewing the organizations books and information related to quality. The administrative staff will stay available on the other side of the closed doors in case the surveyors have questions and they will be available to retrieve additional information.

The team discusses their plans amongst each other which usually consist of reviewing more information such as credentialing, policies and procedures or doing tracers. A tracer is reviewing the list of all hospitalized patients including their age, length of stay and diagnosis and picking a patient out to trace from the moment they arrived at the facility to the present.

During the tracer, the surveyor will be looking to see if standards are met such as writing the medication appropriately, checking the patients vitals and patient teaching. While in the building, the surveyors will note if they see medical staff wash their hands, wear name tags and practice proper patient identifiers such as asking the patients name, birthday and checking the arm band. They will look for clutter, expired packages and any unsafe conditions.

The surveyor will interview the nurse caring for this patientduring the tracer and ask to see, in the chart if all appropriate records are kept. There may be discussion about restraints, use of medication or sedation during a surgical procedure. While tracing a patient the anesthesiologist will be interviewed as will the nurses at admitting and even the people who clean supplies. Every moment of that patients stay is traced and recorded. The patient is often also interviewed about their stay. This process is repeated throughout the survey. The team members are followed closely by senior management and escorted through the building so questions can be answered and charts can be easily retrieved. At each department the group is met by the senior staff of that department.

After each tracer, a report is written by the surveyor. The team meets at lunch and types their reports and shares their finding with each other. They compare notes, express concerns and ask advice of each other. After lunch they are off again to do more of the same.

The second and third morning consists of a brief meeting about the findings the day before. All the organizations leadership meet and listen to what the surveyor found that was good, and that may be a problem but with no hint of the final report.

Each team members has a chance to share their findings and the organizations leadership can ask questions and for clarification.

When sharing with the leadership potential problems, the surveyors do not use names. They are looking for system problems and how the problems can be addressed and approved upon. They are looking for the same problem with each patient, if in fact a problem is found. Is it the individual? Or is it the way things are run there? Often the surveyors have suggestions and will help staff make improvements, but they are not there to give the answers to the staff, they encourage them to come up with their own answers and make it work.

The surveyors can be tough, but they are fair. They know if something is serious and they have no qualms about sharing their concerns. That is, after all what they are there for.

The life safety code specialist spends just one or two days and looks at the roof, the kitchen, the electrical and exit signs. He will ask about the fire drill and how the fire doors work. He will speak to staff about their training and knowledge of emergency situations and protecting the newborns from abduction. He too has an important job and it’s completely related to safety. He gives his presentation at the end of the day and would usually leave before the others.

The final day, senior leadership come to hear what was found to be good, potential problems and anything more serious. At this meeting board members of the facility are often invited.

The report will include RFI’s or Requirements for Improvement. RFI’S can be fixed and improvements made. Too many RFI’s are a potential problem but still each organization is given a chance to fix the RFI’s. Once the surveyors leave, there is now contact with the corporate office of the Joint Commission and that is how contact will continue.

Some final thoughts; The Joint Commission will not fine or discipline the facility. They will give them, when appropriate RFI’s. Too many, depending on the size of the facility can lead to possible loss of accreditation which means loss of funding. In reality, I don’t want to see hospitals lose funding or have their doors closed. I want to see them improve and keep us safe.

Please feel free to comment to this blog.