1. March 2011 The Joint Commission Survey Process Overview
San Antonio APIC
March 2011
The Joint Commission Survey Process Overview

2. TJC Survey Process (hospitals) TJC Chapter Requirements
AGENDA
TJC Survey Process (hospitals)
TJC Chapter Requirements
Periodic Performance Review (PPR)
Survey Readiness
Infection Control & Prevention Chapter
Resources
Discussion & Questions

3. Provide an overview of TJC Survey Process (hospitals)
OBJECTIVES
Provide an overview of TJC Survey Process (hospitals)
Review the TJC Chapter Requirements & Infection Control & Prevention Chapter
Discuss Periodic Performance Review (PPR) & Survey Readiness
Share TJC Survey Related Resources

4. TJC SURVEY PROCESS Unannounced Survey Process
Posted on TJC secure extranet site by 7:30 a.m.
Survey window – 18 to 39 months after previous full survey
Strategic Surveillance System (S3- past survey findings, ORYX® core measure data, data from the Office of Quality Monitoring (complaints and non-self reported sentinel events), data from an organization’s electronic application, and HCAHPS data.
TJC Survey Team Composition (based on size & complexity of your organization) -> Lead Surveyor, Administrator, Nurse, Generalist, Specialist (e.g. lab), Life Safety Code Specialist

5. TJC SURVEY PROCESS
Opening Session (Leadership)– survey overview & orientation to organization
Document Review – Policies, Plans, Meeting Minutes, Census
Individual Tracer Activity– Isolation Patient, Surgical Patient
System Tracers – depends on the size/complexity of your organization
Infection Control & Prevention
Medication Management
Data Use
Program Specific Tracers – suicide prevention, patient flow, lab integration
Competency & Medical Staff Credentialing & Privileging

6. TJC SURVEY PROCESS Infection Control & Prevention System Tracer
Composition of Team (IC members -> Employee Health, Pharmacy, Lab, EVS, Facilities Management, Nursing, Procedure Areas)
Scheduled after Document Review & Individual Tracers
Discussion - review of accomplishments and opportunities
Exit Briefing & Exit Summary - “Summary of Survey Findings Report”
Direct Impact Standards
Condition of Participation Deficiencies -> Central Office Review
Indirect Impact Standards

7. Infection Control & Prevention System Tracer
IP Program Assessment & Plan
Population Demographics  Annual Plan
MDROs -> Lab (culture result tracking), Pharmacy, Dietary, EVS, NPSG, tracking
SSIs -> Health Optimization Prior to Elective Surgery, types of procedures monitored, Joint, Cardiac and Bariatric Surgery
Device Related Infections -> CLABSI, VAP, CAUTI
Review of a patient in isolation as a table top tracer
Type of isolation
Education of staff, patient, visitors
Tracking & Notification

8. TJC SURVEY PROCESS
Potential Accreditation Decision – “Accreditation Survey Findings Report” posted on secure extranet site includes the potential accreditation decision (within 2 days usually)
Central Office Review – COP, Immediate Threat, Situational Decision Rules
Final Accreditation Decision – Evidence Standards Compliance (ESC)
Immediate Threat to Health or Safety
Situational Decision Rules
Direct Impact Standards (45 days)
Indirect Impact Standards (65 days)
MOS – 4 months

9. Continuum of survey activity outcomes
PA/ A
Preliminary Accreditation (Applicable to the Early Survey Policy - 1st time accreditation of new organization)
Accredited (Compliance with all standards or successfully addresses RFIs in an ESC within 45 or 60 days)
AFS
Accreditation with Follow-up Survey (not in compliance with specific standards that require a follow-up survey in 30 days to 6 months – ESC still applicable)
Cont
Contingent Accreditation (fails Accreditation with Follow-up Survey or does not have a required license, follow-up survey in 30 days)
PDA
Preliminary Denial of Accreditation (Immediate Threat to Health or Safety, Failure to resolve requirements of AFUS after two opportunities or CA; or Significant Standard Non-compliance) DA
Denial of Accreditation
Reports that meet a decision rule that automatically triggers a PDA, Cont or AFS or a report with a CMS Condition level or APR deficiency will be reviewed by TJC Central Office. Reminder: CMS conducting validation surveys

10. TJC CHAPTER REQUIREMENTS
Chapter – NPSG, EC, EM, HR, IC, LD, MS,PI,TS
Standard (Requirement) – statements that define the performance expectations and/or structures or processes
Rational – background, justification, additional information
Element of Performance (EP) – identify performance expectations
References – help to identify related standards/EPs
Icons

11. TJC CHAPTER REQUIREMENTS
Numbering Requirements
Standard six digit number broken down into three sets of two numbers each
For Example, IC
First two letters are the chapter acronym
First two digits refer to the Roman numeral in the outline
Second two digits refer to the letter under the Roman numeral in the outline
Last two digits refer to the standard number
Chapter
Roman Numeral
Letter in Outline
Standard Number IC 02 04 01
Infection Prevention and Control
II (section – Implementation) D

12. TJC CHAPTER OUTLINE - IC
I. Planning
A. Responsibility (IC )
B. Resources (IC )
C. Risks (IC )
D. Goals (IC )
E. Activities (IC )
F. Influx (IC )
II. Implementation
A. Activities (IC )
B. Medical Equipment, Devices, and Supplies (IC )
C. Transmission of Infection (IC )
III. Evaluation and Implementation (IC )

13. Situational Decisional Rules / Contingent Accreditation
TJC Glossary of Terms EP
Element of Performance M
Measure of Success required D
Written Documentation required
2/3
EP Criticality Tag: 2=Situational Decisional Rule; 3=Direct Impact
A/C
Scoring Category: A=Y/N; C=3 strikes out
What is the time line for resolution of non-compliant findings?
What is the immediacy of risk to the patient?
Immediate Threat
Situational Decisional Rules / Contingent Accreditation
Direct Impact
Indirect Impact
Short
High
EP Scoring Scale
Insufficient Compliance 1
Partial Compliance 2
Satisfactory Compliance
Low
Long

14. Example – Scoring and Icons
Scoring Category
Documentation
Scoring Scale
Criticality Tag 3
MOS

15. TJC Periodic Performance Review
Tool for self-assessing compliance with standards and requirements between on-site surveys
Process to identify potential areas of concern, and opportunities to make ongoing adjustments.

16. PERIODIC PERFORMANCE REVIEW
Organization’s self assessment with chapters, standards and EPs
Noncompliant Standard – Plan of Action(POA); Measure of Success (MOS)
Completed annually one year after survey
Several Options for submission
Full PPR and 3 other options

17. PERIODIC PERFORMANCE REVIEW
PPR ASSESSMENT BY CHAPTER CHAMPION
CHAPTER CHAMPION completes Scoring
Facility Administrator concurs/revises scoring
Submission to TJC
Action Plans
MOS
OFI
Review using resources
Questions: Contact Facility Administrator

18. TJC Survey Readiness PPR – self assessment & POAs/MOS
Mock Individual/Patient, Progam Tracers – IP and Team
Infection Prevention & Control related examples
Isolation Patient Tracers – MDRO’s, Precautions
Surgical Patient
Instrument handling and reprocessing
Biohazard Waste
Food and Nutrition Services
Environment of Care
Practice Infection Control System Tracer

19. TJC Survey Readiness Facility TJC Readiness Regional Mock Tracers
Scorecard & Executive Summary
Facility & System OFI
Follow-up Regional Mock Tracers

20. Infection Control & Prevention Chapter Summary - Planning
IC – Identifies individual(s) responsible for program
IC – Leaders allocate needed resources for program
IC – Hospital identifies risks for acquiring and transmitting infections
IC – Based upon risks hospital sets goals to minimize possibility of transmitting infection
IC – Hospital has an IP and Control Plan
IC – Hospital prepares to respond to an influx of potentially infectious patients

21. Infection Control & Prevention Chapter Summary - Implementation
IC – Hospital implements its IP and Control program
IC – Hospital reduces the risk of infections associated with medical equipment, devices, and supplies
IC – Hospital works to prevent transmission among patients, LIPs and staff
IC – Hospital offers vaccination against influenza to LIPs and staff

22. Infection Control & Prevention Chapter Summary – Evaluation & Improvement
IC – Hospital evaluates the effectiveness of its IP and Control Plan

23. National Patient Safety Goals
Goal 7 – Reduce the risk of health-care associated infections
Meeting Hand Hygiene Guidelines
Preventing MDRO’s
Preventing CLABSI
Preventing SSI
2012 – VAPs and CAUTI
Sentinel Events – separate chapter

24. 2010 Challenging Standards - IC
Identify risks for acquiring/transmitting infection. IC /EP#1&2 (Identify & prioritize risks based on location, community, and services provided)
Reduce the risk of infections associated with medical equipment, devices, supplies. • IC /EPs #1,#2, #4 (Implement infection prevention and control activities when cleaning, performing disinfection, sterilizing, and storing) {DIRECT IMPACT}

26. Resources Available JCR & TJC Publications – Perspectives
Infection Prevention & Control Publications
TJC Hospital E-dition 2011 (updated July and before January)
TJC website (
BoosterPak
R3 Report
TJC Leading Practice Library
Joint Commission Center for Transforming Healthcare (
IP Networking

27. TJC BoosterPak (As of January 2011 two BoosterPaks Published)
Full version available on HITT site.

28. R3 Report (As of January 2011 One Report Published)

29. Leading Practice Library

30. Leading Practice Library