1. Survey Preparation Carrie Bradford, MHA, RHIA, CPMSM, CPCS
Judy Eastridge, MBA, CPMSM
Stephanie Russell, BS, CPMSM, CPCS

2. Basic Information
Accrediting Body
TJC
NCQA
DNV
HFAP
CMS
AAAHC

3. Who’s Leading the Team? Know Your Role Participative Supportive
Clear Expectations
Organizational Resources

4. TJC Self Assessment – Focused Standards Assessment (FSA)
Myopic hazards!
Document compliance
Findings versus RFIs (Requirement for Improvement)
Other

5. Where Are the Answers? Methodical Identify BY Standard YOUR Compliance
Bylaws
Policies

6. TJC Not Just Medical Staff Standards Leadership Human Resources
Infection
Other?

7. Variability By Surveyor  By Location Focused Standards Assessment
Ambulatory
Hospital
Disease Specific (this should be scheduled)
Focused Standards Assessment

8. Surprise – We’re Here
TJC “usually” includes Credentialing in Every Survey
CMS “usually” does also
They May Follow Each Other
Physician Leadership Interview
Who should participate?
Quality process/leadership

9. Deemed Status CMS Validation Follows TJC Survey
More Routine now than ever
CoPs and EPs

10. Horror Stories

11. Dreams Come True

12. Questions