Current Survey Process Used By JCI

Question: You are on a Mock Joint Commission Survey Team for the hospital. The hospital will conduct an unannounced mock survey in the next 3 months. The team leader has asked you to bring suggestions of activities to include in the upcoming internal (mock) survey to share at the next meeting. You want to include activities that simulate a real Joint Commission on-site survey. You have several ideas from networking with your peers on the regional and state levels of your professional associations and by participating in AHIMA's CoP for Joint Commission Accreditation. Your next step is to visit the Joint Commission website at www.jointcommission.org and review the current survey process to gain a better understanding of what is being done during the on-site survey. What suggestions would you include in the next mock survey conducted? Develop a Mock survey plan for this organization by using information from the reading and at the Joint Commission's website. Be sure to include information on tracers, the National Patient Safety Goals, physician compliance with documentation standards, medication safety, etc. Answer: Introduction: A mock survey can be extremely beneficial to an organization. It can help an organize measure the milestones achieved, compliances met and can give it the scope for improvement in the future. It helps to prepare for the real survey which can enable an organization to get prestigious accreditations and increase the value of an organization (Chamberlain Hamner, 2007). Current Survey Process used by JCI: The most common method used by JCI for an on-site survey process is Tracer Methodology. In this process information about the care or treatments provided to a patient or the services provided is obtained through the delivery of health care procedures of an organization. It involves a number of steps which enables the surveyor to recognize the issues related to performance issues of an organization (Rothchild, 2000). The various kinds of tracers used by JCI are Individual Tracer activity: In this process a particular patient is selected and then the information is gathered about the treatment, care or services the patient has received at the hospital. This is done through interviewing, questionnaires and scrutiny of documents related to the patient (Uselton, Kienle, Murdaugh Coe, 2010). System tracer activity: In this process a particular system is selected and information is gathered about the processes involved in the system, the communication and co-ordination with other departments through interviews, questionnaires and documents. Data management, Medication management and infection control are three areas which are evaluated by this method. Accreditation program-specific tracers: These tracers recognize the points of risks and concerns of safety related to the services, treatment etc. Second generation tracers: These involve in-depth study of a particular topic, process etc. The issues that are prone to high risks can be surveyed by this process as a detailed survey would help overcome many hazards which can threaten the safety of patients. Examples of these issues would be disinfection, diagnostic imaging, cleaning, sterilization etc (Joint, 2007). The new mock survey process: Objectives: To make the staff aware of the regulatory standards To identify if the hospital is in compliance of the rules To know the compliances required for an accreditation The team: It would comprise of all the clinical as well as the non-clinical staff. There would be a core team of the administrator, the physicians and the nurse. There would be a specialty team comprising of staff from safety and facility management, infection control, Pharmacy and laboratories. The process: The date would be scheduled for the survey process and it would be announced to all the staff. All the documents required in the survey should be ready in appropriate format. Some of the required documents are Organization chart Departmental heads job description Administrative policies and procedures- Admission, transfer and discharge Policy for care of vulnerable patients Safe keeping of patient belongings policy. Employee manual. Annual evaluation records Attendance records Training requirements assessment process Patient safety plan Risk management plan Apart from these all the information related to survey should be organized properly. The survey would be conducted in all the departments through interviews and questionnaires. The staff as well as patients should take part in the survey. The feedback from the patients is important as it would give a scope of improvement before the real survey (Steenstra, 2000). Special reviews of the following should be taken care of Co-ordination of communication between different departments. Whether the orders of physicians were followed. Aid care plans. Monitoring to check if supervisory visits are done regularly. Clinical information about every patient. Bio hazards control. Infection control. Fire safety. Action plan All the deficiencies must be noted down and informed to the respective departments. A time-limit should be given to work upon it and a follow up should be done after that. Every department should be given a checklist and a supervisor to check if the work is getting done according to the checklist. The reports should be reviewed by the core committee and if the work is not done actions should be taken. Meeting is to be held in every department to brief about the entire process and then work upon it (Brace, 2013). Budget: In order to make the changes finances are very important. It might not be possible to overcome all the deficiencies in one go. The budget should be made keeping in mind the areas of priorities or utmost importance. Conclusion It is most important to analyze the deficiencies and find the solutions after a mock survey. Also, regular reviews to check whether the deficiencies have been overcome can make a mock survey successful. References: Brace, I. (2013). Questionnaire design : how to plan, structure and write survey material for effective market research. London: Kogan Page Limited. Chamberlain, K. Hamner, C. (2007). The JCAHO mock survey made simple. Marblehead, Mass: Opus Communications. Joint. (2007). 2008 Standards for Behavioral Health Care (SBHC. City: Joint Commission on. Rothchild, S. (2000). Advances in Tracer Methodology Volume 2 A collection of papers presented at the Sixth, Seventh, and Eight Symposia on Tracer Methodology plus other papers selected by the editor. Boston, MA: Springer US. Steenstra, H. (2000). Interaction and the standardized survey interview the living questionnaire. Cambridge New York: Cambridge University Press. Uselton, J., Kienle, P., Murdaugh, L. Coe, C. (2010). Assuring continuous compliance with Joint Commission standards a pharmacy guide. Bethesda, Md: American Society of Health-System Pharmacists.