On May 27, 2020, The Joint Commission (TJC) announced that it will begin returning to survey activities in the month of June (visit The Joint Commission’s website to view the official announcement). But, what will that mean? What will surveys look like? Which surveys will come first? How, specifically, will it all work?
The following is a brief overview of what we know based on open dialogues between consulting groups such as ours and Joint Commission leadership. We encourage you to continue to visit The Joint Commission website for updates and to reach out to your Joint Commission Account Representative for organization-specific questions. And, of course, we will also be here to help.
What’s been happening since March
Before we discuss the new survey “normal,” we will review what’s been going on in recent weeks.
Collaboration with HHS
The US Department of Health and Human Services (HHS) and TJC have been collaborating on a number of issues.
- The agencies continue to discuss requirements and survey processes for hospital quality and medical staff privileging. We understand that these discussions surround two points:
- the possible extension of a hospital system’s board’s ability to award privileges on behalf of individual hospitals within the chain (allowed under an 1135 waiver during the pandemic), and
- possible enhancements to the survey process for these functions, which stem from congressional concerns over the effectiveness hospital peer review activities.
- The 1135 waivers extended by CMS have been incorporated into The Joint Commission’s standards and will be honored during TJC surveys.
- HHS has requested input from the industry about possible CMS requirements that offer little value for healthcare organizations or the patients they serve. This dialogue was stimulated by the thought “if it wasn’t necessary to do this (waived) function during the pandemic, why would it be necessary to perform the function once the pandemic ends?” TJC has collected comments from a number of sources and plans to submit its suggestions soon. Greeley intents to forward its thoughts separately to CMS about potential changes in the Conditions of Participation and EMTALA.
- The Joint Commission has encouraged Health and Human Services to make behavioral health services readily available to healthcare personnel across the nation as they work under incredible stress in an uncertain and potentially dangerous setting.
Approaching a new “normal” survey process
Returning to Travel
Surveyors will be carefully returning to the field beginning the first week in June. Things are changing rapidly, but this is what we know as of May 27. Account representatives are beginning to dialogue with organizations with surveys due or past due (surveys like follow-up surveys based on adverse findings, validation surveys and routine triennial resurveys of accredited organizations).
- TJC has about 2,200 surveys that are due or past due since survey operations were suspended on March 16.
- Calls are going to all organization types: hospitals, critical access hospitals, behavioral health organizations, home care organizations, clinical laboratories, etc.
- TJC is only contacting organizations in the 449 of 3250 counties and territories within the US (14%) that are considered “low risk” based on data from the New York Times database to see if they would be capable of fully participating in a survey.
- To be considered “low risk” the number of cases within the county must be:
- trending downward (number of cases for most recent 14 days less than or equal to the number of cases for the prior two weeks), and
- less than 5 cases per 1000 residents averaged over the most recent 14 days.
TJC does not intend to review organizational activities during the pandemic. Mark Pelletier, TJC’s Chief Operating Officer, has instructed surveyors to review organizational performance from before March 16, 2020 and after the conclusion of the community-wide emergency. Findings will not be based on activities between those two dates.
The conclusion of the community-wide emergency will be the date that
- the federal state of emergency has ended, or
- the state and local emergency for the hospital’s community has ended, or
- the hospital is no longer operating under its emergency management plan…whichever is latest.
Mr. Pelletier also indicated that CMS intends to allow a grace period after the end of the pandemic for certain activities to resume (e.g. 60 days after the conclusion to catch up on medical staff reappointments), but the scope and all details have yet to be clarified.
There were several hospitals with “open” surveys when the curtain came down on field activities on March 16, meaning that the organization required an on-site follow-up survey to verify correction of serious requirements for improvement.
TJC has been working with these organizations virtually during the down time to review corrective actions. It is likely that most of these “open” surveys can be closed without an on-site visit. However, those that will still require an onsite review will move to the top of the list once their community moves into the low risk cohort.
Virtual Survey Activities
TJC has had very good experiences with the virtual survey process (portions of a survey conducted via tele-link instead of on site, in person survey activities). A few examples:
- 29 nursing care facilities underwent full surveys (required by a new Florida state law) completed via tele-link. This included the Life Safety Code review, whereby TJC’s LSC surveyors “inspected” selected areas of the organization by video link (face time, Zoom, etc.).
- Six hospitals are in the process of going through entirely virtual full surveys for initial accreditation.
- SAMHSA (US Department of Health and Human Services, Substance Abuse and Mental Health Services Administrations) has approved TJC to review opioid treatment programs via virtual surveys.
- CMS has approved tele-surveys of clinical laboratories in concept. These virtual surveys will begin once the details are approved by CLIA (Clinical Laboratory Improvement Act) representatives.
In summary, although the details are still a little fuzzy, TJC plans to include virtual elements to almost all surveys going forward (subject, of course, to CMS approval). The current thought is that documents (Life Safety Code drawings, fire suppression/alarm inspection testing and maintenance records, equipment and utilities inspection records, quality plans, committee minutes, and similar documents) would be reviewed off site prior to the onsite visit. The onsite part of the survey would then focus on areas of concern identified during the offsite document review and other subjects of general concern such as infection prevention, high-level disinfection, suicide prevention and emergency preparedness.
TJC is also exploring additional virtual-survey strategies, such as observing procedures via tele link, reviewing distant off-site locations using electronic tablets, and reviewing the electronic health record via remote access.
But these are still the early days. For example, TJC is still dealing with logistics, such as figuring out how many Zoom licenses it needs. And all involved will need more experience and evaluation cycles before virtual survey processes become stable.
On-site Survey Restrictions
- For now, TJC surveyors who go on site will wear medical masks whether or not it’s required by the hospital.
- Surveyors will request that the number of escorts / observers be limited.
- The team will observe the six-foot social distancing rule, meaning that fewer individuals will be able to attend systems tracers or other meetings, unless they can somehow find larger meeting rooms that accommodate appropriate spacing and ventilation.
- Hospital surveyors will not perform in-room observations of aerosol-producing procedures, including (subject to change):
- Intubation and Extubation (unless the air changes are equivalent to those in an operating room)
- 2nd Stage of Labor
- Patients on continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP)
- Chest PT (Chest Physical Therapy)
- Airway suctioning
- Sputum induction
- Ventilator Weaning
- Positive Pressure Ventilation
- Dental procedures
- …and likely others
Enhanced Surveys for Hospital Outpatient Services
At the insistence of CMS, TJC will soon enhance the review of the physical environment for hospital-based outpatient services.
- Outpatient services that meet the definition for an Ambulatory Healthcare Occupancy in the Life Safety Code (locations where four or more patients are simultaneously rendered incapable of self-evacuation) will be surveyed by a Life Safety Code specialist.
- Outpatient services in business occupancies will be sampled and clinical surveyors will review selected features of the physical environment in addition to clinical care. This will necessitate an increase in the overall time allotted for clinical survey activities.
- TJC has developed the following list of features that will be reviewed during these outpatient service visits:
- Life Safety Code Drawings
- Means of Egress
- Locked/blocked exits
- Exit access
- Exit discharge Illumination
- Battery back-up
- Corridor widths
- Corridor obstructions
- Visible exit signs
- Above Ceiling
- Electrical Outlets
- Electrical Panels
- Safety Data Sheets (SDS)
- Security / Access
- Smoke / Fire Barriers
- Fire Extinguishers Inspection
- Mounting and Visibility of Extinguishers
- MRI locations
- Biohazardous and Pharmaceutical Waste
- Alcohol-based hand rub (ABHR) Dispensers
- Eye Wash Stations
- Storage Rooms
- Medical Equipment
- High-level disinfection
- Cylinder Storage
- Sprinklers/Sprinkler Systems
- Fire Drills
The annual 1-day briefings from TJC to the field, traditionally held in New York, Chicago, Los Angeles, Dallas, and other hubs in August and September each year, have been canceled for 2020. Instead, TJC plans to hold two 2-hour live webinars later this year, which would then be available for streaming.
TJC is seeking suggestions for the content and focus of these webinars, which are in the early days of planning.
That’s all for now…
At the risk of repeating ourselves, the new survey “normal” is a moving target. We only have a rough idea what the virus has in store for us, and much depends on what we as a society do in the days and weeks ahead.
We will keep our ear to the ground and let you know what we know. We are here to help you navigate this challenging time. If you have questions regarding compliance during the time of COVID-19, or are interested in assessing your organization’s survey preparedness, please contact us at 888.749.3054.
Stay safe and well.
© 2023 Chartis Clinical Quality Solutions. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors. It does not constitute legal advice.