By Jim Fedele, CBET
Our industry has many regulatory and accrediting organizations, including the Department of Health, DNV and The Joint Commission to name a few. Meeting the requirements imposed by these organizations is part of our daily activities. However, when one of these organizations come into our facility it is always a little stressful. We recently had our Joint Commission inspection. I would like to share our experience with the survey.
Anyone who uses The Joint Commission as their accreditation body knows that their surveys are unannounced. Once in the survey window they can show up at any time to survey the hospital, this is done to encourage facilities to ensure a constant state of readiness and compliance. Our three-year anniversary date was closing in and we were expecting them any day. Our survey this year was going to include an additional campus that we added to our license. This meant they would be sending five surveyors and staying for four days. It was funny to hear the prediction on when they were coming as if someone knew the secret to their schedule. Most of us had concluded that if we made it past Tuesday in any given week our survey would not be happening that week.
I had just returned from a trip to Seattle to visit my son. I had taken the red eye home Sunday night and took Monday off to recover from the travel. I reported to work Tuesday, still feeling the jetlag from the travel. I had just sat down and booted up my computer when I heard the announcement “Please Welcome the Joint Commission.” Admittedly, my heart sank followed by a burst of adrenaline as I prepared myself for the ensuing barrage of requests I would soon be getting. In no time, my phone lit up. I was getting calls from many people looking for information. As you can imagine with five surveyors, there were many people all at once looking for information. My team and I rose to the occasion and provided information as quickly as possible. The survey team was incredibly collegial and educative, this helped everyone feel at ease and present their best self when answering questions. However, they were also very thorough. They seemed to check every nook and cranny in our facilities. At the beginning of each day, they provided a debriefing of what they found and the day’s schedule. I felt like they were really digging deep to find things.
At 4 p.m. on Friday they gave us an exit report, they were very complimentary of our programs and called us a “learning organization.” We made it! Here are some of the things they focused on.
Life safety guy:
- Looked at every smoke door
- Looked at the RPTs in OR
- Looked for penetrations
- Asked about process for changing the use of spaces.
EOC:
- Looked at annual evaluation, said plans were adequate but would like them to be more robust
- Stressed the plans should be a living document, changing as things change within the facility
- Looked for clutter and for med gas valves being blocked or mislabeled
- Explained importance of scope, objectives and policies for EOC
- Explained to us that it wasn’t required to have semiannual EOC tours, that we could decide what works for us to conduct surveys. Do a risk assessment and maybe do some areas more and some areas less.
- Also liked that all work requests for equipment under OEM contract were in the CMMS
- Said all medical equipment needs to be on an inventory for CMS, including IT equipment and facility equipment
- Looked at sterilizer records and dialysis machine records.
They looked at the overall cleanliness and condition of equipment and said all equipment should be free of adhesive residue from tape and stickers.
The nurse surveyor inspected the radiology department and offsite centers. She asked to see imaging records. Both the items we fixed and items the OEM fixes.
At the end of the day, our survey was pretty good. There are just a few minor things we need to report on. For me, I don’t feel nearly as nervous when they come anymore. I am getting used to talking with them. With all the facilities I manage now, there is always one “in the window” for a Joint Commission inspection.
