Proactive Approaches to Avoid a Joint Commission Survey Disaster

By Bud Pate

The best action hospitals can take to avoid a Joint Commission survey disaster in 2019 is to proactively diagnose common Joint Commission problem areas within an organization. By identifying those areas that may put a hospital at risk during accreditation, organizations can actively work towards amending the problems before a survey. Nearly half of the hospitals undergoing a Joint Commission survey this year will find themselves with one or more Medicare condition-level deficiencies triggering an onsite ‘MED DEF’ (short for Medicare Deficiency) survey within 45 days after their full survey. This 45-day MED DEF survey will focus on a subset of findings, generally those that relate to the Medicare conditions of participation that were out of compliance during the first visit. 

A growing number of hospitals will also face preliminary denial of accreditation (PDA) when the Joint Commission determines that patients are at risk due to the severity, pervasiveness, or repetitive nature of the survey findings. Hospitals whose survey triggers PDA will face an additional follow-up survey about two weeks after the MED DEF survey (60 days from the original survey). Assuming these two follow-up surveys go well, the hospital will then undergo an additional four-month sustainability re-survey and enhanced scrutiny during their next full survey, usually between 18 to 33 months from the previous (problem prone) survey. 

There are two approaches hospitals can take to minimize risk of landing in the unlucky half of organizations who face survey disaster: Focus and Simplify. 

FOCUS

The most common survey problem areas are:

• The environment of care (including fire and life safety) 
• The identification and protection of individuals at high risk for suicide 
• High level disinfection/sterilization

Below is an overview of what hospitals and health organizations can do to proactively focus on these issues to avoid future Joint Commission survey problems.

Environment of Care (EC) and Life Safety (LS) issues account for most Joint Commission survey findings. Therefore, the environment of care oversight committee should focus on true systems issues rather than the endless stream of ‘one-off’ issues.  For example, the committee should focus on the process for identifying and sealing smoke/fire wall penetrations rather than each penetration individually. They should focus on the process of identifying and implementing interim life safety measures rather than perseverating about each individual construction project.

The following EC/LS issues are frequent triggers for MED DEF and PDA determinations:

• Ligature resistant construction in behavioral health settings
• The monitoring and response system for temperature and humidity in operating rooms
• Air flow in sensitive or ‘critical’ areas, such as the flow of air between the decontamination room and the packaging/sterilization room in central sterile supply

The list of EC/LS most frequently cited issues changes over time, so it’s important to track changes and trends in EC/LS findings. Pay attention to each edition of Joint Commission Perspectives, stay alert for FAQs as they are published, and bookmark websites that discuss emerging EC/LS survey challenges.

Suicide Prevention and flaws in the identification and protection of patients who are at high risk for suicide account for many condition-level survey findings. The largest problem is that organizations overcommit and underperform. The most significant contributor to these findings is unrealistic expectations for screening and assessments that cause patients to be on precautions unnecessarily. Therefore, it behooves each hospital to thoroughly understand suicide prevention requirements and take the time to create simple, appropriate, safe, and implementable solutions. 

High-level Disinfection/Sterilization has remained problem prone over recent years and often leads to condition-level deficiencies (and sometimes Immediate Threat to Life). So, remember to:

• Pay attention to the entire disinfection/sterilization cycle such as areas of equipment collection, transportation and storage, and not just the disinfection/sterilization segment
• Invest in a comprehensive disinfection/sterilization gap analysis
• Develop a long-term improvement plan that takes the pervasive nature of disinfection/sterilization into account

SIMPLIFY AND COMPLY

Hospitals should focus on fixing the systems issues they know about, rather than becoming paralyzed by a never-ending cascade of new issue identification. The only path to fix a broken system is to make it easier to follow. Making things unnecessarily complex is easy. Making an inherently complex process simple is incredibly difficult, but essential.

About The Greeley Company

The Greeley Company is the leader in healthcare consulting, education and interim staffing solutions; with unmatched experience in the areas of regulatory compliance, accreditation, bylaws and peer review, as well as credentialing and privileging. Greeley’s mission is to help healthcare organizations improve efficiency, comply with regulations and standards, achieve practitioner engagement and alignment, and excel in delivering high-quality, cost-effective patient care. For more information, visit www.greeley.com.

Bud Pate joined The Greeley Company in 2004 and has subsequently been involved in countless patient safety and compliance consultations, including over 100 successful Joint Commission appeals and countless improvement activities focused on avoiding Medicare termination. He has authored seven books on quality, patient safety, patient flow and compliance.