Joint Commission Surveys: Unannounced – and in 2010 – Unplanned

So you heard that the survey process was unchanged for 2010. Not so fast.

The Joint Commission’s (TJC) 2010 Survey Guide subtlety outlines a survey process that holds some surprises for the new year. The latest surprise includes a new challenge for hospitals, the requirement to develop an agenda with surveyors minutes before the survey begins.

Survey agendas vary greatly based on the number and complement of surveyors and services offered by the organization. This fact remains unchanged. What is new is the challenge to come up with a survey agenda within the first hours of survey. While this new approach allows hospitals greater flexibility in setting their agendas, the side effect may be greater chaos on the first morning of survey if they do not plan ahead.

The 2010 Survey Guide includes a Survey Activity List that outlines the sessions routinely positioned in most surveys. This list will be used by the surveyor complement to develop an agenda during the survey’s opening sessions. Hospitals will continue to receive information about the number of survey days and their surveyor complement during the pre-survey planning call with their account representatives. But now, they will have to communicate the survey agenda to staff in real time.

Stemming the Chaos
To avoid a scramble on the day of survey, hospitals may wish to outline a draft agenda to serve as a discussion document for surveyors upon their arrival. While changes may need to be made in real time to accommodate survey areas that have limited hours (like clinics), some sessions can be pre-positioned to align with the hospital’s normal routine.

Anticipating the needs of the physicians involved in the credentialing process and pre-positioning their interviews around surgical schedules or office hours can be effective in assuring their availability for the session. Hospitals with four- or five-day surveys will have the greatest flexibility in drafting agendas that can be vetted by multiple groups. Smaller organizations with less survey days may wish to create sample agendas that propose ideal sessions for a M-W survey or a W-F survey.

Taking a few minutes to address preferences and “blackout” times for survey activities in anticipation of the unannounced survey can assist in avoiding additional surprises. Rolling the dice and waiting until the morning of survey to discover the survey agenda may create more stress than necessary. Hospitals need to consider their options in managing this new aspect for surveys in 2010.

Need more?

Contact Ruth Elzer at (513) 241-0142 x 114 to discuss this latest change and receive a SAMPLE survey agenda for 2010 from which to customize your own survey plan.