The Joint Commission Mock Tracer Made Simple: 17th Edition
The following are some general tips from The Joint Commission Mock Tracer Made Simple on readiness regarding various aspects of a survey:
• Documents for review: The list of documents that must be available includes items that can be gathered in advance as well as items that will need to be pulled the morning of the survey. The documents list is located in The Joint Commission’s survey activity guide; review this list in advance. Many organizations keep a binder ready to go in the event of an unannounced survey. Conduct a practice run to ensure that documents that need to be located on the morning of the survey (e.g., lists of patients, procedures, surgeries, ambulatory/diagnostic testing appointments, etc.) can be retrieved quickly and efficiently. There is also a list of items that may be requested when the surveyor identifies an issue. Ensure that these items are current and accessible.
• Closed medical record review session: There is no scheduled closed medical record review; the focus will be on current, open records. If questions about compliance with documentation in the record arise, or if there are no patients of a certain type in the hospital at the time of the survey, the surveyors may ask for a sample of closed records to review. For example, if there are no patients in restraints at survey time, the surveyors will ask for a sample of closed records involving patients in restraints. Also, the medical record delinquency form must be completed and ready for the survey team. Don’t lose sight of your delinquency rate; it can affect your accreditation status if it exceeds twice the average monthly discharges.
• Competency assessment processes: The surveyors will identify times toward the end of the survey to review documentation of employees’ competency and the credentials of staff members with privileges. Expect names of staff members who interacted with surveyors during tracers to make up the bulk of this review. Also expect surveyors to request specific competency information during patient tracer activity.
• Visits to patient care settings and departments: This activity is incorporated into tracers. Note that any given area might be visited once, multiple times, or not at all. Therefore, the entire organization should
be survey-ready.
• Environment of care review: A formal session will be scheduled to review documents and to discuss issues related to environment of care. Currently, every hospital will have a Life Safety Code® specialist visit for at least two days during the survey.
• Emergency management: For hospital surveys, a formal session will be scheduled to review emergency management. Surveyors will evaluate the hazard vulnerability analysis, the emergency operations plan (EOP), the prior year’s EOP, and any emergency management drills and resulting actions taken.
• Daily briefing: This valuable meeting will occur from day two until the last day of the survey. Listen carefully to the issues that surveyors raise during the briefing to identify possible recommendations, and challenge any findings believed to be incorrect while the surveyors are still on-site. Use the issue resolution times to address any open items that need further clarification. Disputes with the survey team
should be channeled to the team leader.
• Off-shift survey visit: The Joint Commission no longer includes an off-shift visit during reaccreditation surveys, but it reserves the right to conduct such visits in “for cause” surveys.
• Exit conference: Organizations will receive their preliminary survey report at the exit conference. Remember, following the survey, you still have an opportunity to clarify (i.e., remove) disputed findings from this report. You should exercise this option when necessary and without reservation.
• Complex surveys: Organizations that have customarily had a “tailored survey” with ambulatory, long term care, homecare, or addictive disease surveyors added to the core team should expect to see a greater degree of integration, with only one leadership conference and members of the core team performing assessment of specialty areas whenever possible.
• Review of Measures of Success (MOS) from FSA: If you did not select Option 3 for your PPR, you may be asked to share the results of any required MOS.
• Compliance with the United States Pharmacopeia (USP)—National Formulary Chapter on Compounding, Sterile Precautions: Although The Joint Commission supports the goals of USP 797 requirements, the accreditor will not survey your compliance with these requirements.
• Compliance with CMS’ Conditions of Participation (CoP): Intense focus on standards derived from CMS’ CoP has become normal throughout a survey. For hospitals that use Joint Commission accreditation for deemed status, compliance is crucial. The electronic edition of the accreditation manual provides a crosswalk between the standards and CoPs.