Just before the second COVID-19 surge hit at the end of 2020, The Joint Commission (TJC) was completing about 10 percent of its scheduled on-site surveys. By the time full survey activities resume (which is not likely until May 2021 or after), TJC will be at least a full year behind schedule. TJC and other accreditors will need to use novel approaches to work through the backlog.
TJC has been experimenting with virtual survey activities to help close the gap. They have learned that many elements of surveying can be completed successfully without the survey team being on site. Some reviews, such as clinical laboratory surveys, are completed entirely via remote connection: documents are reviewed, interviews are conducted, machinery is inspected, and the survey report is prepared without the surveyor ever visiting the lab.
Some of these virtual survey activities may fade away as the pandemic loses steam; other virtual survey elements are likely to become a permanent part of the process. The “virtual document review” is almost certain to become a permanent change and has the potential to leave many hospitals vulnerable to adverse accreditation actions.
Off-Site Document Review – Why It Matters
We expect the seemingly trivial shift to off-site document review sessions to herald significant changes to the focus and severity of survey findings. Whereas environment of care/life safety (EoC/LS) surveyors have always had plenty of time for a structured and thorough review of EoC/LS documents (reflected in the mountain of EoC/LS findings in a typical survey report), clinical and leadership surveyors have had little time or structure to facilitate a comprehensive documents review:
- Clinical surveyors borrowed time here and there for brief document reviews, usually related to a question raised during tracers.
- The documents request in the Survey Activities Guide was vague, leading to the wrong documents being provided for on-site review.
- There was little structure to the clinical documents review process, meaning that each surveyor looked at documents through their own lens.
The Joint Commission is getting serious. With more time and structure allowed by pre-survey virtual document reviews, the challenges above will be resolved. As issues identified during previous Joint Commission or state/CMS surveys reappear on subsequent surveys, the Commission’s focus will be on leadership. And persistent failures of leadership will ultimately result in denial of accreditation.
More Time, More Focus, More Risk
With the growth of the pre-survey virtual documents review session, clinical surveyors will have the time and structure to thoroughly and consistently review past state/CMS survey findings, minutes of key oversight committees, critical policies and plans, and other documents important to the survey process. What does this change imply?
- The survey team will be better able to dig deep into previously identified issues to see if they’ve truly been fixed.
- Surveyors will have the time and information for an in-depth analysis of executive leadership effectiveness.
- There can be more depth to the review of policies, procedures, and guidelines addressing high risk processes (infection prevention, suicide precautions, restraint, etc.), enabling a deeper evaluation of implementation at the point of care and service.
- As structured document review tools are developed and improved, the survey process will become more consistent, surveyors will be reminded of problem prone aspects hiding in various documents (quality plans, contracts, etc.), and the identification of patterns of non-compliance over time will become easier to spot.
New Process Could Bring Positive Outcomes
While a virtual document review process may seem daunting, we believe it will enable more consistency between survey teams, allowing the hospital to maintain focus on significant areas of vulnerability from year to year and survey to survey. Leadership will have an additional incentive to focus on significant vulnerabilities rather than being distracted by a flood of less impactful findings. The enhanced focus on consistent, sustained compliance should result in lasting improvements to problem prone processes. It should also help most hospitals abandon the “whack-a-mole” approach to survey preparation in favor of a more focused and enduring improvement process, leading hospitals toward high reliability.
What To Do
We’re all learning how to do things differently as a result of the unprecedented year 2020. Preparing for the more in-depth review of leadership effectiveness signaled by the virtual survey documents review process is just one sign of change. This shift in TJC’s focus toward sustained compliance with high-risk requirements has been in progress for years. It is incumbent upon your organization’s accreditation readiness efforts to change accordingly.