Folks back home surely have called off the search…
By Steve MacArthur, Hospital Safety Consultant
We knew it was going to happen eventually, but our friends in Chicago have made it official (just in time for the implementation of Daylight Savings Time—for those of you participating), the return of the (more or less) completely unannounced surveys by The Joint Commission (see the first article in the March 10 edition of Joint Commission Online). To be honest (and I try never to be anything but), I really can’t say how far behind they are on the survey front. I can’t imagine that there’s not going to be some serious catching up to do, and, since the public health emergency is still in play, I’m not sure how much time they’ll be given by the feds to reach some sort of survey plateau.
Presumably, they will continue to rely on the CMS COVID data (we talked about that a little while back; if you’ve somehow managed to misplace that link, you can find it here) to determine where the trouble spots might be (if you look at the latest data, the results are promising; hopefully we won’t be remembering the beginning of March as the—yet another—calm before the storm), so if you’re in a “red” county, that may be enough to avoid being in the first wave. I suppose the other dynamic is how survey teams will they be able to field—it sounds like this is going to be a busy week for folks, so if they show up on your front door step, please know that this community is standing by with best wishes for success.
As an adjunct to the return of the survey, TJC unveiled the 2021 Survey Activity Guide, which, among other things, formally speaks to the elimination of the Environment of Care interview session, indicating that topics previously covered in the session will find their way into the EC/LS tracer activities. Thus, effectively giving the LS surveyors another hour or so to wander the halls, with the implication being that they may go to/get to places in your house where they’ve not previously been. I’m not entirely certain, though I suppose if you have a fair amount of square footage there may be one or two spots that might not have been ransacked before, but I’m guessing you have a pretty decent idea of where they’ve not been, so it might be worth kicking those tires, so to speak. We know for a pretty fair certainty that they will be visiting the kitchen (after all, there’s a checklist and far be it for a checklist to go unchecked…).
They’ve also updated/revised the list of documents, including the return (don’t call it a comeback!) of the Statement of Conditions and Basic Building Information, something of a focus on water management programs (make sure you have your ASHRAE and CDC ducks in a row) and the management of line isolation monitors (if you have them). And, of course, the perennial attentions to the Management Plans (I’m not going to say anything more about those for a bit…) and annual evaluation process. Oddly enough, it appears that the document list also includes things that are not required to be documented, but rather are in place to remind you and the surveyors of some specific expectations like, oh, how ’bout, managing safety risks. I almost forgot about that…
So, hopefully the survey process will be less lion and more lamb as we get things rolling again. I think most organizations are experiencing some variation of PTSD and I don’t think that kicking folks in the head is going to be very helpful. The fact that healthcare has managed to keep things going over the past 12 months is a testament to the effectiveness of our processes, etc. I’m not expecting pats on the back (as deserved as they may be), but I do expect some reason in the administration of the survey process—or at least, that’s my hope—especially for everyone that’s in the barrel for this coming few weeks.
Please be well and stay safe—and keep doing what you’re doing. You folks are amazing, and don’t forget it!
About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.