Transcription
Ambulatory Care AccreditationSurvey Activity GuideJanuary 2021
Survey Activity Guide forAmbulatory Care OrganizationsJanuary 2021
What’s New?New or revised content is identified by underlined text.Changes effective January 1, 2021 Surveyor Planning Initial – This activity has been eliminated for all programs. NOTE:Surveyors will need as many documents as possible from the program-specific DocumentLists available for the Surveyor Arrival and Preliminary Planning activity. Special Issue Resolution and Surveyor Planning/Team Meeting – Special IssueResolution takes place throughout the survey; that is, surveyors do not typically wait toaddress issues until a scheduled time on the agenda. Therefore, these activities will nowoccupy the same 30-minute timeframe on the survey agenda and either one or the otheractivity will be conducted by the surveyor based on need. Surveyors will inform theorganization which activity will take place. Survey Activity List – Updated to clarify applicability of the Life Safety Code BuildingAssessment activity. Life Safety Code Building Assessment – Specified the NFPA editions that are beingsurveyed. Behavioral Health Care and Human Services Accreditation Program Document Listand Survey Activity List – Updated to reflect the change in the accreditation programname. Laboratory Accreditation Program Document List – List reorganized and one new itemincluded Sample Survey Agendas – Updated to reflect elimination of Surveyor Planning Session,combining of Special Issue Resolution and Surveyor Planning/Team Meeting activities intosame time slot, and Ambulatory Surgery Center, sample two-day agenda reflects changes inthe Life Safety Surveyor schedule of activities. Ambulatory Surgery Center Life Safety & Environment of Care Document List andReview Tool – Tool has been expanded to include additional environment of care relateddocuments for review. Imaging Document Review Guide – Introducing a new tool to help organizations compileimaging services documents and data needed for surveyor review, based on the imagingmodalities provided by the organization.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 2021
Ambulatory Health Care and Office-Based Surgery OrganizationsSurvey Activity Guide (SAG)Table of ContentsHow to Use this GuidePrior to the SurveyPreparing for Surveyor ArrivalSurvey Readiness GuideSurvey Document ListSurvey ActivitiesDuring the surveySurveyor Arrival and Preliminary Planning SessionOpening ConferenceOrientation to Your OrganizationIndividual Tracer ActivitySpecial Issue ResolutionSurveyor Planning/Team MeetingDaily Briefing (applicable if survey is two or more days)Competence Assessment and Credentialing & PrivilegingEnvironment of Care and Emergency Management SessionLife Safety Code Building AssessmentSystem Tracer-Data ManagementClinical Leadership and Staff Discussion – Bureau of Primary Health Care onlyGovernance Discussion Session – Bureau of Primary Health Care onlyLeadership SessionSurveyor Report PreparationCEO Exit Briefing (Optional)Organization Exit ConferenceFollowing the SurveyWhat Happens After Your Joint Commission SurveyAppendixTable of ContentsBehavioral Health Care and Human Services Accreditation Program Document ListBehavioral Health Care and Human Services Accreditation Survey Activity ListLaboratory Accreditation Program Document ListLaboratory Accreditation Survey Activity ListTips for Conducting Mock TracersProgram Specific Tracer – Continuity of CareSystem Tracer – Infection ControlSystem Tracer – Medication ManagementSample Survey AgendasAmbulatory Surgery Center Life Safety and Environment of Care Document List andReview ToolImaging Document Review 535455565758-6465-7778-80Key: The following abbreviations are used throughout this Guide to identify specific accreditation programs and the survey activitiesapplicable to the program. AHC – Ambulatory Health Care (surveyed from the Comprehensive Accreditation Manual for Ambulatory Health Care and notthe Hospital Accreditation Manual) OBS – Office-Based Surgery (surveyed from the Comprehensive Accreditation Manual for Office-Based Surgery and not theAmbulatory Care Accreditation Manual)Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 2021
How to Use this GuideThe Joint Commission’s Survey Activity Guide for ambulatory care and office-based surgery organizationsis available on your organization’s Joint Commission Connect extranet site.This guide contains: Information to help you prepare for survey A description of each survey activity that includes session objectives, an overview of the session,logistical issues, and suggested participants Sessions are listed in the general order that they are conducted.A template agenda with a list of onsite survey activities are posted to your organization’s JointCommission Connect extranet site once the application is reviewed and processed by your accountexecutive. When the agenda and activity list are available, please review the material and think about thepeople you might involve in the survey. The activity list includes a column in which you can recordparticipant names or positions next to each of the sessions. Identifying key participants (and their phonenumbers) for each session, including back-ups, is important. Consider including possible meetinglocations and surveyor work space in your planning documents. Review the sessions in this SurveyActivity Guide to learn about what will occur during the activity.The template agenda and activity list include suggested duration and scheduling guidelines for each ofthe sessions. On the first day of survey, there will be an opportunity for you to work with the surveyor(s)to prepare an agenda for the visit that will fit with your day-to-day operations.Please Note: Not all of the activities described in this guide are contained in the activity list or on theagenda template. Many of the activities will take place during individual tracer activity. Surveyors willincorporate these into the onsite survey when they are applicable to your organization.Complex organizations (surveyed under more than one accreditation manual or that have more thanone service under one accreditation manual), will receive an activity list and agenda template for each ofthe programs being surveyed (e.g., behavioral, home care, laboratory).For multiple services surveyed under a single accreditation program, be sure to include contact namesand phone numbers from all of your organization’s services. For example, Ambulatory Care might havethe following services: Ambulatory Surgery Centers, Diagnostic Imaging Services, Diagnostic SleepCenters, or Urgent Care.Also identify names or positions and phone numbers of activity participants from all of the programs onthese activity lists. Identify when it would be most effective to conduct an activity with all programspresent (e.g., Leadership, Daily Briefing, and System Tracer--Data Management) and suggest this to thesurveyors when they arrive.This Survey Activity Guide is created for small and large organizations. Some organizations will have onesurveyor while others will have multiple surveyors. For Ambulatory Surgical Centers using The JointCommission for deeming purposes, this will include a clinician(s) and Life Safety Code surveyor.If you have any questions about the number of surveyors who will arrive at your site, please contact yourAccount Executive. If you are unsure of your Account Executive’s name or phone number, call the JointCommission at 630-792-3007 for assistance.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 20214
PRIOR TO THE SURVEYCopyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 20215
Applicable ProgramsAHC and OBSPreparing for Surveyor ArrivalOverviewThe surveyor(s) arrive unannounced or with short notice for most surveys. Exceptions to theunannounced survey process include: Initial accreditation surveys that are not a Deemed Status survey (30-day advance notice) Early Survey Option – 1st and 2nd surveys that are not a Deemed Status survey (30-day advancenotice) Intra-cycle Monitoring (ICM) Option 2 and Option 3 surveysExceptions to the unannounced survey process may change at any time. Changes are published in theJoint Commission newsletter Perspectives.A seven-business day advance notice is given for the following Ambulatory Care AccreditationProgram re-survey types: Very small Ambulatory as defined in the Accreditation Process section of the accreditationmanuals (short notice)Department of Defense facilitiesBureau of Prisons facilities and contracted prison facilitiesImmigration facilitiesOffice-Based Surgery practicesTelehealth ServicesSleep CentersAmbulatory surgery centers that are not using accreditation for deemed status purposesSurgery/anesthesia servicesMedical/dental servicesSpecified diagnostic/therapeutic servicesMobile diagnostic servicesPlease Note: Organizations offering procedures/services from more than one of the above service types(i.e. surgery/anesthesia medical/dental telehealth) are not eligible for a short notice survey.Planning in advance for the surveyor’s arrival helps staff be better prepared for the survey. Whether thesurveyor arrival is announced or unannounced, the first hour of the surveyor’s day is devoted to planningfor your survey activities. This planning requires review of specific documents that can be found on theSurvey Document Lists for each accreditation program in the pages that follow. If these documents arenot available when the surveyors arrive, they immediately begin to evaluate the care, treatment, orservices provided to one of your patients served through an individual tracer.Preparing for SurveyPrepare a plan for staff to follow when surveyor(s) arrive. The plan should include: Greeting surveyor(s): Identify the staff usually at the main entrance of your organization. Tellthem about The Joint Commission and what to do when the surveyor(s) arrive. Explain theimportance of verifying any surveyor’s identity by checking his or her Joint Commission pictureidentification badge. Also log into your Joint Commission Connect extranet site to validate thesurveyor’s identity when possible. Who to notify: Identify leaders and staff to notify when surveyors arrive, including the individualwho will be the surveyor’s “contact person” during the survey. Identify alternate individuals in theevent that leaders and staff are unavailable. Create a list of their names and telephone numbers.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 20216
A location for surveyor(s): Ask surveyors to wait in the lobby until an organization contact personis available. Surveyor(s) will need a location that they will call their “base” throughout the survey.This location should have an electrical outlet, phone access, and internet access.Validation of survey: Identify who will be responsible for the validation of the survey and theidentity of surveyors. Identify the steps to be taken for this process. (See Surveyor ArrivalSession for these steps.)The Survey Readiness Guide is a tool that helps you plan the survey (See page 8).Document Lists: Your organization should be prepared to have documents available for thesurveyor(s) as soon as your organization validates their identity. If this information is notimmediately available for surveyors at the Surveyor Preliminary Planning Session, they will beginthe survey with an individual tracer.Staff: Identify staff who will accompany the surveyors during the survey.Expectations for the survey: Identify your organization’s expectations for the on-site survey andwho will share these with the surveyor(s)Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 20217
Survey Readiness GuideActions to take when thesurveyor(s) arrivesResponsible StaffComments:Greet surveyor(s)Check the Joint CommissionConnect extranet site fornotification of survey eventBe sure to designate someone to accessyour organization’s Joint CommissionConnect extranet site.Verify identity of the surveyor(s)Check the picture ID to ensure that they arefrom The Joint Commission. Also log intoyour Joint Commission Connect extranet siteto validate the surveyor’s identity, whenpossible.Determine where they will meetwith your teamLocation:Note: Please download the entire Survey Activity Guide for additional information on how to prepare forsurvey.The Survey Document List and Survey Activities list appears on the pages that follow. Please reviewthem to assist you in preparing for your survey. The Survey Activities list includes the potential surveyactivities that can occur on an accreditation survey, including the suggested duration, and suggestedtiming for these activities. This information will allow your organization to begin identifying participants thatneed to be involved in the survey. The Survey Activities list includes a column for your organization to usefor recording participant names, possible meeting locations, times that could conflict with participantavailability, or any other notes. Please work with your surveyor(s) to confirm the best day(s) and/or time(s)for specific survey activities to take place. Contact your Account Executive with any questions related tothis information.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 20218
Survey Document ListAs an Ambulatory Care or Office-Based Surgery organization, you will need to have the followingavailable for the surveyor(s) to review (depending on the type of survey or setting) during the SurveyorArrival and Preliminary Planning Session.Please note that this is not intended to be a comprehensive list of documents that may be requestedduring the survey. Surveyor(s) may need to see additional documents to further explore or validateobservations or discussions with staff.Note: The 12-month reference in the following items is not applicable to initial surveys.ItemNo.1ItemsComments/NotesPerformance / Quality Improvement Data from the past 12 months2Infection Control surveillance data from the past 12 months3Infection Control Plan4Environment of Care management plans and annual evaluations5Meeting minutes pertaining to Environment of Care topics for the 12-monthsprior to survey, if applicable6Organization chart7A map of the organization, if available8List of all sites that are eligible for survey9List of locations where services are provided, including anesthetizing locations10List of locations where high-level disinfection and sterilization is in use11Any reports or lists of patient appointment schedules or surgery schedules foreach day of the survey12A list of contracted services13Name and extension of key contacts who can assist surveyors in planningtracer selection14Most recent culture of safety and quality evaluation dataFor Ambulatory Surgery Centers (ASC) Deemed Status Surveys:15List of surgeries from the past six months16List of cases in the past 12-months, if any, where the patient was transferredto a hospital or the patient died (Note: The 12-month time frame for thisdata applies to all ASC organizations seeking deemed status, whetherundergoing a Joint Commission initial survey or resurvey.)17Documents related to the infection control program (e.g., description, policy,procedures, surveillance data)18Infection Control Surveyor WorksheetCopyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 20219
Documents Related to CMS Emergency Management Final Rule applies to Deemed AmbulatorySurgical Centers, Rural Health Clinics, and Federally Qualified Health CentersNote: Document formats may vary, and many of the documents listed below may be included in theEmergency Management Plan.19Prioritized Potential Emergencies (Hazard Vulnerability Analysis)20Emergency Management Plan21Documentation of annual review and update of Emergency Management Plan,including communication plans22Continuity of Operations Plan23Documentation of completed/attempted contacts with contact local, state,tribal, regional, federal EM officials in organization’s service area24Annual training25Patient evacuation procedures26Tracking system for patients sheltered on-site and patients relocated toalternate site27Integrated EM system risk assessments, plan, and annual reviewFor Bureau of Primary Health Care (BPHC) surveys:28List of Board of Directors membership, including the user/patient/consumerstatus, occupational/areas of expertise, geographic location, and specialpopulation representation29Board minutes (past 12 months on all surveys); annual Uniform Data System(UDS) report30Most recent BPHC Notice of Grant Award (with any conditions or managementassessment items)31Items from most recent BPHC Grant Application: Health Care Plan, Scope ofServices; Overall Summary (if available)32Health Center’s bylaws, strategic plan, and needs assessmentFor End Stage Renal Disease (ESRD) surveys:33Life Safety drawing of the facility (current and accurate drawings of the facilityw/fire safety features and related square footage noted)34List of current patients by name, separated into modalities35Current in-center hemodialysis patient schedule by days & shifts with anyisolation patients identified (seating chart or assignment sheet)Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 202110
36List of dialysis patients who have been designated as “unstable” for any monthin the past 3 months, including reason for unstable and month37List of all dialysis patients who were involuntarily discharged (not transferred toanother outpatient dialysis facility) from this facility in the past 12 months38List of all discharged dialysis patients categorized as “lost to follow up” (i.e. nottransferred out or discontinued dialysis) for past 12 months39List of residents of long-term care (LTC) facilities for whom the organization isproviding onsite dialysis treatment40List of dialysis patients receiving services from the facility who were admittedfor inpatient care within the past 6 months41Infection logs for past 6 months42Policies and procedures for dialysis patient care, including: Water anddialysate testing, emergency patient response, infection control, and dialyzerreprocessing/reuse, if applicableCopyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 202111
Survey ActivitiesActivity NameDurationActivityScheduling GuidelinesSurveyor Arrival and PreliminaryPlanning30-60 minutes1st day, upon arrivalOpening Conference15 minutes1st day, as early as possibleOrientation to Your Organization30-60 minutes1st day, as early as possibleIndividual Tracer activityoccurs throughout thesurvey; the number ofindividuals who surveyorstrace varies by organizationAt a time negotiated with theorganizationEnd of each day except last;can be scheduled at othertimes as necessaryStart of each survey dayexcept the first day; can bescheduled at other times asnecessaryAfter some individual traceractivity has occurred; at atime negotiated with theorganizationAfter some individual traceractivity has occurred; at atime negotiated with theorganizationAfter some individual traceractivity has occurred; at atime negotiated with theorganization. If this is theonly system tracer takingplace during survey, thetopics of Infection Controland Medication Managementwill be covered in thisdiscussion.Towards the middle or endof survey at a timenegotiated with theorganizationIndividual Tracer60-120 minutesLunch30 minutesIssue Resolution OR SurveyorPlanning/Team Meeting30 minutesDaily Briefing15-30 minutesCompetence Assessment andCredentialing & Privileging30-60 minutesEnvironment of Care andEmergency Management45-90 minutesSystem Tracer – DataManagement30-90 minutesLeadership60 minutesSurveyor Report Preparation60-120 minutesLast day of surveyCEO Exit Briefing10-15 minutesLast day of surveyOrganization Exit Conference30 minutesLife Safety Code BuildingAssessment45-90 minutesCopyright: 2021 The Joint CommissionNotesLast day, final activity ofsurveyOccurs on all AmbulatorySurgical Center surveys,both deemed status andnon-deemed status; toevaluate compliance with theAmbulatory Health CareOccupancies chapters of theLife Safety Code (NFPA101-2012) and Health CareFacilities Code NFPA 992012;AHC/OBS Organization Guide January 202112
Activity NameProgram Specific Tracer –Continuity of CareDurationActivity60-120 minutesSystem Tracer – Infection Control30-60 minutesSystem Tracer – MedicationManagement30-60 minutesBureau of Primary Health CareSurveys only -- GovernanceDiscussion45-60 minutesBureau of Primary Health CareSurveys only – Clinical Leadership& Staff Discussion60 minutesCopyright: 2021 The Joint CommissionScheduling GuidelinesNotesAlso occurs on surveyswhere four or moreindividuals aresimultaneously renderedincapable of selfpreservationThis focused tracer occursduring time designated forIndividual Tracer Activity.After some individual traceractivity has occurred; topicmay be covered during theData Management systemtracer depending on thelength of surveyAfter some individual traceractivity has occurred; topicmay be covered during theData Management systemtracer depending on thelength of surveyAfter some individual traceractivity has occurred; at atime negotiated with theorganizationAfter some individual traceractivity has occurred; at atime negotiated with theorganizationAHC/OBS Organization Guide January 202113
DURING THE SURVEYCopyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 202114
Applicable ProgramsAHC and OBSSurveyor Arrival and Preliminary PlanningSessionParticipantsSuggested participants include organization staff and leaders as identified in the Pre-survey Planningprocess.DurationThe surveyor(s) will arrive between 7:45-8:00 a.m. unless business hours, as reflected in the surveyapplication, indicate that your organization opens at a later time. The suggested duration of thepreliminary planning session is approximately 30 to 60 minutes.Surveyor Arrival Activities Notify key organization members as identified in the pre-survey planning session of the surveyor(s)arrival. Validate that the survey is legitimate by accessing your Joint Commission Connect extranet site. Astaff member in your organization with a login and password to your Joint Commission Connectextranet website will follow through with this by:o Accessing the Joint Commission’s website at www.jointcommission.orgo Under ‘Action Center,’ log in The Joint Commission Connect extranet siteo Enter a login and passwordo If you cannot access The Joint Commission Connect extranet site to validate the surveyor surveyors, call your Account ExecutiveYour organization’s Joint Commission Connect extranet site contains the following information(posted by 7:30 a.m. on the morning of your survey):o Notification of scheduled Joint Commission event authorizing the surveyor’s presence forthe unannounced surveyo Surveyor name(s), picture and biographical sketcho Scheduled survey dates If you have not already downloaded a copy of your survey agenda, do so at this time. Begin gathering and present documents as identified in the Survey Document List applicable to yourprogram(s). Surveyors will start reviewing this information immediately.OverviewSurveyor(s) will need a workspace they can use as their “base” for the duration of the survey. This areashould have a telephone, internet access, and access to an electrical outlet. The surveyor(s) will needthe name and phone number of a key contact person who will assist them in planning for the survey andtheir tracer selections.After the surveyor(s) identification has been verified, they will immediately begin planning for traceractivity by reviewing the documents you provide them (refer to the Survey Document List on thepreceding pages). The surveyor(s) will begin discussing the focus of the survey with the other surveyors(when applicable). If documents are not available for surveyors to review during this session, they willproceed to areas where care, treatment, or services are provided and begin individual tracer activity.For complex organizations surveyed under more than one accreditation manual or for more than oneservice under one accreditation manual, surveyors review information from all accredited programs. It isimportant to have documents available at this session for each program being surveyed. See appendicesfor program documentation lists and sessions.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 202115
For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and areusing The Joint Commission for ADI certification Organizations will receive no notice of the survey event prior to surveyor arrivalFor organizations electing Primary Care Medication Home (PCMH) certification Provide the surveyor with the "Primary Care Medical Home Self-Assessment Tool." If you havecompleted the PCMH self-assessment tool, provide it to the surveyor(s). A copy of the tool can beobtained on The Joint Commission’s ambulatory care section of the website.For Ambulatory Surgery Centers (ASC) Deemed Status Surveys Two active patients are required at the time of survey, preferably during Day 1. Surveyors will observe at least one surgical procedure from the pre-operative phase through to therecovery room and discharge phase during the survey. A schedule of surgical procedures is neededfor planning this observation. Surveyors will use the list of surgeries from the past six months to select a sample of closed medicalrecords for review. At a minimum, surveyors will:oSelect 20 records for a facility with a monthly case volume exceeding 50.oSelect at least 10 records for lower volume ASCs.The sample size may be expanded as needed.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 202116
Applicable ProgramsAHC and OBSOpening ConferenceParticipantsSuggested participants include members of the governing body and senior leadership (representing allaccredited programs/services). Attendees should be able to address leadership’s responsibilities forplanning, resource allocation, management, oversight, performance improvement, and support in carryingout your organization’s mission and strategic objectives. Leaders of the medical staff should alsoparticipate, when applicable.DurationThe duration of this session is approximately 15 minutes. Immediately following this session is theOrientation to Your Organization. If possible, designate a room or space that will hold all participants andwill allow for an interactive discussion. Inform surveyor(s) at this time of any agenda considerations thatmay impact the activities for the day.OverviewDuring this session, the surveyor(s) will: Describe the structure of the survey Answer questions your organization has about the survey Review your organization’s expectations for the survey For PCMH Certification Surveys: Explain that the survey will include an evaluation of compliancewith PCMH-specific requirements.The surveyor(s) will introduce themselves and describe each component of the survey agenda. Thesurveyor(s) will describe the System Tracers they will conduct. It is important for you to discuss andreview your organization’s expectations for the onsite survey with the surveyor(s). Questions about theonsite visit, schedule of activities, availability of documents or people, and any other related topics shouldbe raised at this time. Surveyors will also take time to introduce your organization to the revisedClarification procedures and new SAFER reporting process.Note: When a situation is identified that could be a threat to health and safety, surveyors contact The JointCommission administrative team. The Joint Commission will either send a different surveyor to investigatethe issue or the surveyor on site will be assigned to investigate. Investigations include interviews,observation of care, treatment, and service delivery, and document review. Your cooperation is animportant part of this process. Surveyors will discuss the findings with the Joint Commission administrativeteam and outcomes will be communicated to your organization when a decision is reached.Copyright: 2021 The Joint CommissionAHC/OBS Organization Guide January 202117
Applicable ProgramsAHC and OBSOrientation to Your OrganizationParticipantsSuggested participants are the same as those in the Opening Conference. They include members of thegoverning body and senior leadership (representing all accredited programs/services). Attendees shouldbe able to address leadership’s responsibilities for planning, resource allocation, management, oversight,performance improvement, and support in carrying out your organization’s mission and strategicobjectives.DurationThe suggested duration of this session is approximately 30-60 minutes.OverviewDuring this session, the surveyor(s) become acquainted with your organization. They learn how yourorganization is governed and operated and explore your organization’s performance improvementprocess. There is no need to prepare a formal presentation. This session is an interactive discussionand may be combined with the Opening Conference.Governance and operations-related topics for discussion include: Organization’s mission, vision, goals, and strategic initiatives Organization structure Operational management structure Information management, including the format and maintenance of medical records Contracted services and performance monitoring of contracted services Patient safety initiatives National Patient Safety Goals (July 1 ,2019 for Medical Centers only: New and revisedrequirements at NPSG.03.05.01 related to anticoagulation therapy) Community involvement Leader’s role in emergency management planning Organization activities related
Exceptions to the unannounced survey process may change at any time. Changes are published in the Joint Commission newsletter Perspectives. A seven-business day advance notice is given for the following Ambulatory Care Accreditation Program re-survey types: Very small Ambulatory as defined in the Accreditation Process section of the .
