Ambulatory Care Accreditation Survey Activity Guide For Health Care Organizations 2016
The Joint Commission Survey Activity Guide for Ambulatory Care Organizations 2016
What s New? New or revised content is identified by underlined text. Survey process and guide contents remain unchanged for January 2016. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016
Ambulatory Health Care and Office-Based Surgery Organizations Survey Activity Guide (SAG) Table of Contents Page Number How to Use this Guide 4 Prior to the Survey Preparing for Surveyor Arrival 6-7 Survey Readiness Guide 8 Survey Document List 9-10 Survey Activities 11-12 During the survey Surveyor Arrival and Preliminary Planning Session 14-15 Opening Conference 16 Orientation to Your Organization 17-18 Surveyor Planning Session 19 Individual Tracer Activity 20-22 Special Issue Resolution 23 Surveyor Team Meeting/Planning Session 24 Daily Briefing (applicable if survey is two or more days) 25 Competence Assessment and Credentialing & Privileging 26-27 Environment of Care and Emergency Management Session 28-30 Life Safety Code Building Assessment 31-32 System Tracer-Data Management 33 Clinical Leadership and Staff Discussion Bureau of Primary Health Care only 34-35 Governance Discussion Session Bureau of Primary Health Care only 36 Leadership Session 37 Surveyor Report Preparation 38 CEO Exit Briefing (Optional) 39 Organization Exit Conference 40 Following the Survey What Happens After Your Joint Commission Survey 42-43 Appendix Table of Contents 45 Behavioral Health Care Accreditation Program Document List 46 Behavioral Health Care Accreditation Survey Activity List 47-48 Laboratory Accreditation Program Document List 49 Laboratory Accreditation Survey Activity List 50 Tips for Conducting Mock Tracers 51 Program Specific Tracer Continuity of Care 52 System Tracer Infection Control 53 System Tracer Medication Management 54 Sample Survey Agendas 56-60 Key: The following abbreviations are used throughout this Guide to identify specific accreditation programs and the survey activities applicable to the program. AHC Ambulatory Health Care (surveyed from the Comprehensive Accreditation Manual for Ambulatory Health Care and not the Hospital Accreditation Manual) OBS Office-Based Surgery (surveyed from the Comprehensive Accreditation Manual for Office-Based Surgery and not the Ambulatory Care Accreditation Manual) Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016
How to Use this Guide The Joint Commission s Survey Activity Guide for ambulatory care and office-based surgery organizations is 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 Joint Commission Connect extranet site once the application is reviewed and processed by your account executive. When the agenda and activity list are available, please review the material and think about the people you might involve in the survey. The activity list includes a column in which you can record participant names or positions next to each of the sessions. Identifying key participants (and their phone numbers) for each session, including back-ups, is important. Consider including possible meeting locations and surveyor work space in your planning documents. Review the sessions in this Survey Activity Guide to learn about what will occur during the activity. The template agenda and activity list include suggested duration and scheduling guidelines for each of the 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 the agenda template. Many of the activities will take place during individual tracer activity. Surveyors will incorporate 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 than one service under one accreditation manual), will receive an activity list and agenda template for each of the programs being surveyed (e.g., behavioral, home care, laboratory). For multiple services surveyed under a single accreditation program, be sure to include contact names and phone numbers from all of your organization s services. For example, Ambulatory Care might have the following services: Ambulatory Surgery Centers, Diagnostic Imaging Services, Diagnostic Sleep Centers, or Urgent Care. Also identify names or positions and phone numbers of activity participants from all of the programs on these activity lists. Identify when it would be most effective to conduct an activity with all programs present (e.g., Leadership, Daily Briefing, and System Tracer--Data Management) and suggest this to the surveyors when they arrive. This Survey Activity Guide is created for small and large organizations. Some organizations will have one surveyor while others will have multiple surveyors. For Ambulatory Surgical Centers using The Joint Commission 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 your Account Executive. If you are unsure of your Account Executive s name or phone number, call the Joint Commission at 630-792-3007 for assistance. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 4
PRIOR TO THE SURVEY Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 5
Applicable Programs AHC and OBS Preparing for Surveyor Arrival Overview The surveyor(s) arrive unannounced or with short notice for most surveys. Exceptions to the unannounced survey process include: Initial accreditation surveys that are not a Deemed Status survey (30-day advance notice) Early Survey Option 1 st and 2 nd surveys that are not a Deemed Status survey (30-day advance notice) Intra-cycle Monitoring (ICM) Option 2 and Option 3 surveys 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 re-survey types: Ambulatory Care Accreditation Program Very small Ambulatory as defined in the Accreditation Process section of the accreditation manuals (short notice) Department of Defense facilities Bureau of Prisons facilities and contracted prison facilities Immigration facilities Office-Based Surgery practices Telehealth Services Sleep Centers Ambulatory surgery centers that are not using accreditation for deemed status purposes Surgery/anesthesia services Medical/dental services Specified diagnostic/therapeutic services Mobile diagnostic services Planning in advance for the surveyor s arrival helps staff be better prepared for the survey. Whether the surveyor arrival is announced or unannounced, the first hour of the surveyor s day is devoted to planning for your survey activities. This planning requires review of specific documents that can be found on the Survey Document Lists for each accreditation program in the pages that follow. If these documents are not available when the surveyors arrive, they immediately begin to evaluate the care, treatment, or services provided to one of your patients served through an individual tracer. Preparing for Survey Prepare 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. Tell them about The Joint Commission and what to do when the surveyor(s) arrive. Explain the importance of verifying any surveyor s identity by checking his or her Joint Commission picture identification badge. Also log into your Joint Commission Connect extranet site to validate the surveyor s identity when possible. Who to notify: Identify leaders and staff to notify when surveyors arrive, including the individual who will be the surveyor s contact person during the survey. Identify alternate individuals in the event that leaders and staff are unavailable. Create a list of their names and telephone numbers. A location for surveyor(s): Ask surveyors to wait in the lobby until an organization contact person is 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 the identity of surveyors. Identify the steps to be taken for this process. (See Surveyor Arrival Session for these steps.) Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 6
The Survey Readiness Guide is a tool that helps you plan the survey (See page 7). Document Lists: Your organization should be prepared to have documents available for the surveyor(s) as soon as your organization validates their identity. If this information is not immediately available for surveyors at the Surveyor Preliminary Planning Session, they will begin the survey with an individual tracer. Staff: Identify staff who will accompany the surveyors during the survey. Other planning activities Customer Value Assessment: This questionnaire will be available for completion on your Joint Commission Connect extranet site. The Assessment allows you to tell The Joint Commission what is most important to you about the accreditation process. Your organization's expectations for the onsite survey helps the surveyor(s) organize their evaluation work. This information will allow them to consider your needs and keep the on-site process relevant to your organization. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 7
Actions to take when the surveyor(s) arrives Greet surveyor(s) Survey Readiness Guide Responsible Staff Comments: Check The Joint Commission Connect extranet site for notification of survey event Be sure to designate someone to access your organization s Joint Commission Connect extranet site. Verify identity of the surveyor(s) Check the picture ID to ensure that they are from The Joint Commission. Also log into your Joint Commission Connect extranet site to validate the surveyor s identity, when possible. Determine where they will meet with your team Location: Note: Please download the entire Survey Activity Guide for additional information on how to prepare for survey. The Survey Document List and Survey Activities list appears on the pages that follow. Please review them to assist you in preparing for your survey. The Survey Activities list includes the potential survey activities that can occur on an accreditation survey, including the suggested duration, and suggested timing for these activities. This information will allow your organization to begin identifying participants that need to be involved in the survey. The Survey Activities list includes a column for your organization to use for recording participant names, possible meeting locations, times that could conflict with participant availability, 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 to this information. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 8
Survey Document List As an Ambulatory Care or Office-Based Surgery organization, you will need to have the following available for the surveyor(s) to review (depending on the type of survey or setting) during the Surveyor Arrival and Preliminary Planning Session. Please note that this is not intended to be a comprehensive list of documents that may be requested during the survey. Surveyor(s) may need to see additional documents to further explore or validate observations or discussions with staff. Note: The 12-month reference in the following items is not applicable to initial surveys. Item Items No. 1 Your organization s expectations of both the survey team and the on-site survey experience (Note: This can be completed in advance of the on-site survey using the Customer Value Assessment tool on your Joint Commission Connect extranet site.) Comments/ Notes 2 Performance / Quality Improvement Data from the past 12 months 3 Infection Control surveillance data from the past 12 months 4 Infection Control Plan 5 Environment of Care data including the Statement of Conditions (SOC), if applicable 6 Environment of Care Plans for Improvement from last survey, if applicable 7 Environment of Care management plans and annual evaluations 8 Meeting minutes pertaining to Environment of Care topics for the 12-months prior to survey, if applicable 9 An organization chart 10 A map of the organization, if available 11 List of all sites that are eligible for survey 12 List of locations where services are provided, including anesthetizing locations 13 List of locations where high-level disinfection and sterilization is in use 14 Any reports or lists of patient appointment schedules or surgery schedules for each day of the survey 15 A list of contracted services 16 Name and extension of key contacts who can assist surveyors in planning tracer selection For Ambulatory Surgery Centers (ASC) Deemed Status Surveys: 17 List of surgeries from the past six months Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 9
18 List of cases in the past 12-months, if any, where the patient was transferred to a hospital or the patient died (Note: The 12-month time frame for this data applies to all ASC organizations seeking deemed status, whether undergoing a Joint Commission initial survey or resurvey.) 19 Documents related to the infection control program (e.g., description, policy, procedures, surveillance data) 20 Infection Control Surveyor Worksheet For Bureau of Primary Health Care (BPHC) surveys: 21 Health Center s responses to the Health Center Self-Report Tool for BPHC Program Expectations, if the organization has completed one (this is optional as of April, 2012) 22 List of Board of Directors membership, including the user/patient/consumer status, occupational/areas of expertise, geographic location, and special population representation 23 Board minutes (past 12 months on all surveys); annual Uniform Data System (UDS) report 24 Most recent BPHC Notice of Grant Award (with any conditions or management assessment items) 25 Items from most recent BPHC Grant Application: Health Care Plan, Scope of Services; Overall Summary (if available) 26 Health Center s bylaws, strategic plan, and needs assessment Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 10
Survey Activities Activity Name Duration Activity Scheduling Guidelines Surveyor Arrival and Preliminary Planning 30-60 minutes 1 st day, upon arrival Notes Opening Conference 15 minutes 1 st day, as early as possible Orientation to Your Organization 30-60 minutes 1 st day, as early as possible Surveyor Planning Session 30-60 minutes 1 st day, as early as possible Individual Tracer Lunch Issue Resolution Surveyor Team Meeting/ Planning Daily Briefing Competence Assessment and Credentialing & Privileging Environment of Care and Emergency Management System Tracer Data Management Leadership 60-120 minutes 30 minutes 30 minutes 30 minutes 15-30 minutes 30-60 minutes 45-90 minutes 30-90 minutes 60 minutes Individual Tracer activity occurs throughout the survey; the number of individuals who surveyors trace varies by organization At a time negotiated with the organization End of each day except last; can be scheduled at other times as necessary Mid-day and/or end of each day except last Start of each survey day except the first day; can be scheduled at other times as necessary After some individual tracer activity has occurred; at a time negotiated with the organization After some individual tracer activity has occurred; at a time negotiated with the organization After some individual tracer activity has occurred; at a time negotiated with the organization. If this is the only system tracer taking place during survey, the topics of Infection Control and Medication Management will be covered in this discussion. Towards the middle or end of survey at a time negotiated with the organization Surveyor Report Preparation 60-120 minutes Last day of survey CEO Exit Briefing 10-15 minutes Last day of survey Organization Exit Conference Life Safety Code Building Assessment 30 minutes 45-90 minutes Last day, final activity of survey Occurs on all Ambulatory Surgery Center deemed status surveys; occurs on surveys where four or more individuals are simultaneously rendered incapable of self preservation Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 11
Activity Name Program Specific Tracer Continuity of Care Duration Activity 60-120 minutes Scheduling Guidelines This focused tracer occurs during time designated for Individual Tracer Activity. Notes System Tracer Infection Control System Tracer Medication Management Bureau of Primary Health Care Surveys only -- Governance Discussion Bureau of Primary Health Care Surveys only Clinical Leadership & Staff Discussion 30-60 minutes 30-60 minutes 45-60 minutes 60 minutes After some individual tracer activity has occurred; topic may be covered during the Data Management system tracer depending on the length of survey After some individual tracer activity has occurred; topic may be covered during the Data Management system tracer depending on the length of survey After some individual tracer activity has occurred; at a time negotiated with the organization After some individual tracer activity has occurred; at a time negotiated with the organization Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 12
DURING THE SURVEY Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 13
Applicable Programs AHC and OBS Surveyor Arrival and Preliminary Planning Session Participants Suggested participants include organization staff and leaders as identified in the Pre-survey Planning process. Duration The surveyor(s) will arrive between 7:45-8:00 a.m. unless business hours, as reflected in the survey application, indicate that your organization opens at a later time. The suggested duration of the preliminary 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. A staff member in your organization with a login and password to your Joint Commission Connect extranet website will follow through with this by: o Accessing the Joint Commission s website at www.jointcommission.org o Under Action Center, log in The Joint Commission Connect extranet site o Enter a login and password o If you cannot access The Joint Commission Connect extranet site to validate the survey or surveyors, call your Account Executive Your 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 for the unannounced survey o Surveyor name(s), picture and biographical sketch o 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 your program(s). Surveyors will start reviewing this information immediately. Overview Surveyor(s) will need a workspace they can use as their base for the duration of the survey. This area should have a telephone, internet access, and access to an electrical outlet. The surveyor(s) will need the name and phone number of a key contact person who will assist them in planning for the survey and their tracer selections. After the surveyor(s) identification has been verified, they will immediately begin planning for tracer activity by reviewing the documents you provide them (refer to the Survey Document List on the preceding 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 will proceed 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 one service under one accreditation manual, surveyors review information from all accredited programs. It is important to have documents available at this session for each program being surveyed. See appendices for program documentation lists and sessions. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 14
For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and are using The Joint Commission for ADI certification Organizations will receive no notice of the survey event prior to surveyor arrival For organizations electing Primary Care Medication Home (PCMH) certification Provide the surveyor with the "Primary Care Medical Home Self-Assessment Tool." If you have completed the PCMH self-assessment tool, provide it to the surveyor(s). A copy of the tool can be obtained 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 during the survey. A schedule of surgical procedures will be needed for planning this observation. Surveyors will use the list of surgeries from the past six months to select a sample of closed medical records for review. At a minimum, surveyors will: o Select 20 records for a facility with a monthly case volume exceeding 50. o Select at least 10 records for lower volume ASCs. The sample size may be expanded as needed. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 15
Applicable Programs AHC and OBS Opening Conference Participants Suggested participants include members of the governing body and senior leadership (representing all accredited programs/services). Attendees should be able to address leadership s responsibilities for planning, resource allocation, management, oversight, performance improvement, and support in carrying out your organization s mission and strategic objectives. Leaders of the medical staff should also participate, when applicable. Duration The duration of this session is approximately 15 minutes. Immediately following this session is the Orientation to Your Organization. If possible, designate a room or space that will hold all participants and will allow for an interactive discussion. Inform surveyor(s) at this time of any agenda considerations that may impact the activities for the day. Overview During 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 compliance with PCMH-specific requirements. The surveyor(s) will introduce themselves and describe each component of the survey agenda. The surveyor(s) will describe the System Tracers they will conduct. It is important for you to discuss and review your organization s expectations for the onsite survey with the surveyor(s). Questions about the onsite visit, schedule of activities, availability of documents or people, and any other related topics should be raised at this time. Note: When a situation is identified that could be a threat to health and safety, surveyors contact The Joint Commission administrative team. The Joint Commission will either send a different surveyor to investigate the 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 an important part of this process. Surveyors will discuss the findings with the Joint Commission administrative team and outcomes will be communicated to your organization when a decision is reached. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 16
Applicable Programs AHC and OBS Orientation to Your Organization Participants Suggested participants are the same as those in the Opening Conference. They include members of the governing body and senior leadership (representing all accredited programs/services). Attendees should be able to address leadership s responsibilities for planning, resource allocation, management, oversight, performance improvement, and support in carrying out your organization s mission and strategic objectives. Duration The suggested duration of this session is approximately 30-60 minutes. Overview During this session, the surveyor(s) become acquainted with your organization. They learn how your organization is governed and operated and explore your organization s performance improvement process. There is no need to prepare a formal presentation. This session is an interactive discussion, and 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 Community involvement Leader s role in emergency management planning Cleaning, disinfection and sterilization processes For PCMH Certification Surveys: identify eligible sites Discussion topics include: Leaders processes for identification and monitoring of potential risk areas Leaders approach to completing the Focused Standards Assessment (FSA) Tool and methods used to address areas needing improvement (resurveys only) Management and leadership s oversight and other responsibilities Senior Leadership Role in Improving Performance discussion topics may include: How leaders set expectations, plan, assess, and measure initiatives to improve the quality of services Organization approach to safety, including selection of Proactive Risk Assessment topics, resulting improvements, and Board/Governance involvement in safety issues Provision of staff and resources including time, information systems, data management, and staff training Note: Surveyor(s) will request examples of performance improvement initiatives including evidence that performance was achieved and sustained. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 17
During this session, the surveyors will: For PCMH Certification Surveys Ask about the scope of services provided, (i.e., acute, chronic and urgent care) and the types of services available, (i.e., pediatrics, obstetrics/gynecology, behavioral health, dentistry) Determine how the organization uses health information technology (HIT) to support continuity of care, and the provision of comprehensive and coordinated care The surveyors will also ask leaders to describe processes and infrastructure in place to support the provision of coordinated and comprehensive care, including: 24/7 patient access to prescription renewal requests, test results, clinical advice for urgent health care needs, and appointment availability Addressing patient urgent health care needs 24/7 Identification of interdisciplinary team members Use of an electronic prescribing process and in what locations/areas; and, if the process is not in use throughout the organization ask about plans to expand use The type of providers that serve in the role of primary care clinician Any sites that have non-physicians serving in the role of primary care clinician Processes in place to support patient selection of a primary care clinician For ASC Deemed Status Surveys Verify that the governing body has full legal responsibility for determining, implementing, and monitoring policies governing the ASC s total operation Explore the operational management structure Identify who is responsible for directing nursing services and will ask if this individual a registered nurse Request and review governing body meeting minutes or other documents to verify governing body oversight and accountability for the ASC s Quality Assurance Performance Improvement (QAPI) program. This review can occur during the Surveyor Planning Session or Special Issue Resolution. If applicable, select a sample of contractors working with the ASC and request to see documentation of the most recent contractor performance assessment conducted by the ASC. This review can occur during the Surveyor Planning Session or Special Issue Resolution. Surveyors will observe at least one surgical procedure during the survey. Be prepared to provide a schedule of surgical procedures. Ask about the types of radiologic procedures that are performed in the ASC, and explore whether they are limited to those that are integral to the procedures performed Explore whether the ASC has designated someone to be responsible for oversight of radiologic services For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and are using The Joint Commission for ADI certification Identify who serves as the medical director or supervising physician for advanced diagnostic imaging services. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 18
Applicable Programs AHC and OBS Surveyor Planning Session Participants Joint Commission accreditation contact or other key contact person Duration The suggested duration of this session is approximately 30 to 60 minutes. Overview During this session, the surveyor(s) will review documents provided from the survey document list (see pages 8-9). They will plan for individual tracer activities by reviewing documents such as the schedules and verifying location of organization sites. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 19
Applicable Programs AHC and OBS Individual Tracer Activity Participants Suggested participants include staff and management involved in the individual s care, treatment, or services. Duration The duration of individual tracer activity varies but typically is 60-120 minutes. Overview During tracers, the surveyor(s) will evaluate your organization s compliance with standards as they relate to the care, treatment, or services provided to patients. The majority of survey activity occurs during individual tracers. The term individual tracer denotes the survey method used to evaluate your organization s compliance with standards related to the care, treatment, or services provided to a patient. Most of this survey activity occurs at the point where care, treatment, or services are provided. Initially, the selection of individual tracer candidates is based on your organization s clinical services as reported in your e-application and the general risk areas identified for the accreditation program which are listed in the Intra-Cycle Monitoring (ICM) Profile. Surveyors will also consider any organization-specific risk areas listed in the ICM Profile. As the survey progresses, the surveyor(s) may select patients with more complex situations, who are identified through the system tracers and whose care crosses services. The individual tracer begins in the program where the patient and his/her record of care are located. The surveyor(s) starts the tracer by reviewing a record of care with the staff person responsible for the individual s care, treatment, or services. The surveyor(s) then begins the tracer by: Following the course of care, treatment, or services provided to the patient from entry to the organization through end of episode of care. Assessing the interrelationships between disciplines, departments, programs, services, or units Identifying issues that will lead to further exploration in the system tracers or other survey activities such as Environment of Care and Leadership Sessions Surveyor(s) will try to protect patient confidentiality and privacy and they will seek the assistance of your staff in this effort. Surveyor(s) may use multiple patient records during an individual tracer. The record helps the surveyor follow the care, treatment, or services provided by the organization to the patient. The surveyor(s) may arrive in a setting/unit/program/service and need to wait for staff to become available. If this happens, the surveyor(s) will use this time to evaluate environment of care issues or observe the care, treatment, or services being provided. If there are multiple surveyors conducting the survey, they will make every effort to avoid visiting areas at the same time. Surveyors will try to minimize multiple visits to the same location, although they will need to follow the patient to the areas where services were provided. During the individual tracer, the surveyor(s) will observe the following at a minimum: Care, treatment or services being provided to patients by clinicians, including physicians The medication process (e.g., preparation, dispensing, administration, storage, control of medications) Infection control issues (e.g., techniques for hand hygiene, sterilization of equipment, disinfection, food sanitation, and housekeeping) The process for planning care, treatment or services The environment as it relates to the safety of patients and staff Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 20
For ASC Deemed Status Surveys: Surveyors will observe at least one surgical procedure during the survey During the individual tracer, the surveyor(s) will interview staff about: Intradepartmental and interdepartmental communication for the coordination of care, treatment or services. (e.g., hand offs) The use of data Patient flow through the organization National Patient Safety Goals Patient education Orientation, education, and competency of staff Other issues During the individual tracer, the surveyor(s) will speak with available licensed independent practitioners about: Organization processes that support or may be a barrier to patient care, treatment, or services Communications and coordination with other licensed independent practitioners (hospitalists, consulting physicians, primary care practitioners) Discharge planning, or other transitions-related resources and processes available through the organization Awareness of roles and responsibilities related to the Environment of Care, including prevention of, and response to incidents and reporting of events that occurred During the individual tracer, the surveyor(s) will interview patients and their families about: Coordination and timeliness of services provided Education, including discharge instructions Response time when a call bell is initiated or alarms ring, as warranted by care, treatment or services Perception of care, treatment or services Staff observance of hand-washing and verifying patient s identity Understanding of instructions (e.g., diet or movement restrictions, medications, discharge and provider follow-up), as applicable Rights of individuals served/patients/residents For ASC Deemed Status Surveys: Receipt of patient rights information Other issues For PCMH Certification Surveys: The surveyor(s) will select a patient that has had a test ordered or a referral issued. During the individual tracer, the surveyor(s) will interview staff about: How staff track and follow-up on test results and referral, validated through a review of clinical records Whether recommendations or results from referrals are available to the primary care clinician Whether staff can identify the members of the patient's interdisciplinary team Whether staff can describe, how the interdisciplinary team works to collaborate on patient care Whether staff can describe how patient self-management goals are incorporated into the treatment plan; surveyors may ask to see examples in the clinical record How they assess patient health literacy During the individual tracer, the surveyor(s) will interview patients and their families about: Information provided to them to help select a primary care clinician Information provided to them about how the organization functions and the available services Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 21
Directions they received about obtaining urgent care after the office/clinic is closed and if they have ever needed such care For ASC Deemed Status Surveys: During the individual tracer, the surveyor(s) will interview patients and their families about: How and when the organization provided them with patient rights information --verbally and in writing and prior to the start of their surgical procedure Whether they received financial disclosure information in writing Whether they were provided with written information concerning organization policies on advance directives prior to the start of their surgical procedure. This includes a description of applicable state health and safety laws and a copy of the official state advance directive forms The surveyor(s) will also ask about: Processes in place to ensure safe handling of hazardous materials and waste Radiation exposure monitoring procedures The ASC s timeframe for record maintenance Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 22
Applicable Programs AHC and OBS Special Issue Resolution Participants As requested by the surveyor or survey team Duration The duration is approximately 30 minutes and scheduled toward the end of each day except the last. Overview During this session, the surveyor(s) will explore any issues that may have surfaced during the course of the survey that remain outstanding. Depending on the circumstances, this may include: The review of certain policies and procedures The review of additional patient records to validate findings Discussions with staff to obtain additional information or clarification Review of staff and credentials files Review of data, such as performance improvement results Other issues requiring more discussion The surveyor(s) will inform your organization s contact person about any documentation needed, any staff who they would like to speak with, or locations they want to visit. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 23
Applicable Programs AHC and OBS Surveyor Team Meeting/Planning Session Participants None Duration The duration for this session is 30 minutes. Overview The surveyors will use this session to debrief on the day s findings and observations and plan for upcoming survey activities. Before leaving the organization, the surveyor(s) will return organization documents to the survey coordinator / liaison. If surveyor(s) have not returned documents, your organization is encouraged to ask surveyor(s) for them prior to their departure. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 24
Applicable Programs AHC only Daily Briefing Participants Suggested participants include representative(s) from governance, the CEO/Administrator or Executive Director, the Joint Commission accreditation contact, and other key contact individuals identified by staff. Duration The duration for this session is approximately 15 to 30 minutes, beginning on Day 2. Overview During this session, the surveyor(s) will briefly summarize the survey activities completed the previous day and communicate observations according to standards areas that may or may not lead to findings. Surveyor(s) may ask to hold a daily briefing before concluding activity on the first day, depending on circumstances. If a surveyor cannot participate in this session because he or she is surveying at a remote location, you may be asked for assistance with setting up a conference call to include all surveyors and appropriate staff. The surveyor(s) will make general comments regarding significant issues from the previous day, note potential non-compliance, and emphasize performance patterns or trends of concern that could lead to findings of non-compliance. The surveyor(s) will allow you the opportunity to provide information that they may have missed or that they requested during the previous survey day. You may also present surveyors with information related to corrective actions being implemented for any issues of noncompliance. Surveyor(s) will still record the observations and findings, but will include a statement that corrective actions were implemented by the organization during the onsite survey. Your organization should seek clarification from the surveyor(s) about anything that you do not understand. Note that the surveyor(s) may decide to address your concerns during a Special Issue Resolution Session, later in the day. It is important for you to seek clarification if you do not understand anything that the surveyors discuss. Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 25
Applicable Programs AHC and OBS Competence Assessment and Credentialing & Privileging Participants Suggested participants include staff responsible for the human resources processes; orientation and education of staff; assessing staff competency; assessing licensed independent practitioner and other credentialed practitioner competency. Duration The duration for this session is 30-60 minutes. Applicability This session addresses staff competence and the credentialing and privileging processes for licensed independent practitioners, when relevant. Overview During this session, the surveyor(s) will: Learn about your organization s competence assessment process for staff, licensed independent practitioners, and other credentialed practitioners Learn about your organization s orientation, education, and training processes as they relate to staff, licensed independent practitioners, and other credentialed practitioners Inform the surveyor(s) of your process for maintaining competency records. The review of files is not the primary focus of this session; however, the surveyor(s) verifies process-related information through documentation in staff or credential files. The surveyor(s) identifies specific staff, licensed independent practitioners, or other credentialed practitioners whose files they would like to review. The surveyor(s) discusses the following topics: Internal processes for determining compliance with policies and procedures, applicable law and regulation, and Joint Commission standards Methods used to determine staffing adequacy, frequency of measurement, and what has been done with the results Performance improvement initiatives related to competency assessment for staff, licensed independent practitioners, and other credentialed practitioners Orientation of staff, licensed independent practitioners, and other credentialed practitioners to your organization, and/or job responsibilities Experience, education, and abilities assessment Ongoing education and training Competency assessment, maintenance, and improvement Competency assessment process for contracted staff, as applicable Process for granting of privileges to licensed independent practitioners Other topics and issues discovered during the tracer activity During this session, the surveyors will: For ASC Deemed Status Surveys: Review a sample of staff records for non-physician licensed practitioners providing care in the ASC for evidence of: o Current licenses in good standing o Qualifications o Periodic performance evaluation in accordance with the ASC s policies Review the staff files of contract staff to verify credentials, privileges, evidence of training, as applicable Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 26
Review the qualifications of individuals authorized to deliver anesthesia in the ASC, to determine if they are consistent with regulatory requirements. Verify that the individuals performing procedures have privileges granted by the governing body. Review a sample of credentials files for medical staff (See Sampling Table 1) who have been granted privileges for the following: o state licensure, registration, or state certification as applicable o training and pertinent experience o scope of privileges granted o evidence that they are legally and professionally qualified to exercise privileges granted o evidence of reappraisal within the timeframe specified in the ASC s policy Review the personnel file of the individual designated as responsible for oversight of all radiologic services Review personnel files of selected practitioners and staff for their qualifications and competency assessments related to assigned duties Review staff record of the person responsible for directing infection control activities for evidence of training in infection control For PCMH Certification Surveys: Review the staff or credentials files of one or more clinicians serving in the role of primary care clinician (PCC) for evidence of broad-based education and experience in the provision of primary care. For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and are using The Joint Commission for ADI certification: Review the staff/credential file of the medical director or supervising physician of advanced diagnostic imaging services for evidence of training in advanced diagnostic imaging services obtained through: o o o a residency program experience continuing medical education courses Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 27
Applicable Programs AHC and OBS Environment of Care and Emergency Management Session Participants Suggested participants include individuals familiar with the management of the environment of care and emergency management in all major areas within your organization. This may include the safety officer, security management coordinator, facility manager, building utility systems manager, and the person responsible for emergency management. Duration The duration of this session is approximately 45-90 minutes depending on the type of organization, services provided and facilities, and will consist of two parts: Environment of Care/Emergency Management discussion and Environment of Care tracer. Overview During this session, the surveyor will assess your organization s degree of compliance with relevant standards and identify vulnerabilities and strengths in your organization s environment of care management and emergency management processes. The first part of the session is a group discussion that takes approximately 70% of the allotted time. The surveyor is not the primary speaker because it is not intended to be an interview. He or she listens to the discussion, of the Environment of Care risk categories as indicated in the matrix below, and safety data analysis and actions taken by your organization. In the remaining time, the surveyor observes and evaluates your organization s performance in managing a particular risk or management process in the environment of care. The management process or risk selected for observation is based on the environment of care documents previously reviewed, observation by other surveyors, and knowledge gained during the group discussion of this session. Environment of Care Discussion and Emergency Management (Approximately 70% of session time) Be prepared to discuss how the various Environment of Care risk categories 1 and construction activities, when applicable, are addressed in each of the following six management processes. IMPROVE PLAN MONITOR EC Risk Management Cycle RESPOND IMPLEMENT TEACH Plan What specific risks related to its environment of care have been identified by your organization? Teach How have roles/responsibilities for staff/volunteers been communicated by your organization. 1 The environment of care risk categories include: general safety and security, hazardous materials and waste, fire safety, medical/laboratory equipment, and utilities (see matrix on the next page for applicability of risk categories to each accreditation program). Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 28
Implement What procedures and controls (both human and physical components) does your organization implement to minimize the impact of risk to patients, visitors, and staff? Respond What procedures does your organization implement to respond to an environment of care incident/failure? How, when, and to whom are environment of care problems, incidents, and/or failures reported within your organization. Monitor How is environment of care (both human activities and physical components) monitored by your organization What monitoring activities have taken place within the last 12 months (on re-surveys)? Improve What environment of care issues are currently being analyzed? What actions have been taken as a result of monitoring activities? The following matrix is provided to assist in determining patterns of management process or risk category areas of concern and strengths. SAFETY and SECURITY HAZMAT EMG. MGT FIRE MED/LAB. EQ. UTILITIES CONSTRUCTION PLAN TEACH IMPLEMENT RESPOND MONITOR IMPROVE Copyright: 2016 The Joint Commission AHC/OBS Organization Guide 2016 29