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From the C&A Classroom: The Latest News from the Road: An Update on TJC Survey Process & Requirements

Vintage blackboard or school slate

This month Jill Ryan, Courtemanche & Associates CEO, provided a presentation sharing updates on current trends in regulatory and accreditation compliance including highlights from TJC’s Hospital Executive Briefings held in early October. Nuances in survey process and a sampling of actual findings from surveys of organizations around the country were presented. Here are some highlights.

New/ revised requirements and survey process changes were identified:

  • National Patient Safety Goal on Alarm Management – 2015 was the year for planning and policy and procedure development; effective January 1, 2016, TJC will be looking to see that policies are fully implemented.
  • Organizations are also reminded to assure that the new diagnostic imaging requirements are fully instituted.
  • The decision for Accreditation with Follow-up Survey (AFS) has now been delegated to TJC’s Chief Medical Officer by TJC’s Accreditation Committee, enabling decisions to be issued more expeditiously.
  • For a decision of Preliminary Denial of Accreditation (PDA), all ESCs (for both direct and indirect impact EPs) are due 45 days from date of survey. It is strongly recommended that ESCs get submitted sooner than the 45 day deadline.

A recap of TJC trends:

As has been the case for quite some time, eight out of ten top findings are in the areas of the physical environment – several related to Life Safety and the Environment of Care. Considerations to be aware of:

  • Life Safety survey process – Surveyors are now starting the life safety review early on their first day to allow more time for the building tour to give organizations a chance to respond to any issues with the ventilation in key areas (i.e., OR suite).
  • Documentation review continues to be a significant part of the LS survey process.

There are two tools available to assist organizations with the Life Safety and Environment of Care survey planning processes:

  • A several page tool is available on TJC’s Extranet that can be downloaded to assist organizations in preparing for the document review. In addition, there is also a sample agenda to help with survey planning.
  • The newly released Physical Environment Portal, hosted by TJC and created in collaboration with ASHE is an excellent resource to help organizations tackle challenging areas.

High level disinfection and sterilization of medical equipment is also critical. Following manufacturer guidelines for processing reusable equipment and storing sterile supplies was emphasized.

These are only a few examples of the trends that are occurring in TJC survey processes. Being aware of the most current standards and requirements, fully understanding the survey process and engaging all members of your team will best position organizations for survey success and ultimate patient safety.

Coming Up:

Pre-recorded webinar to be released on November 16, 2015

Journeying to High Reliability for Patient Safety: Reflecting on Achievements and Planning for the Coming Year
This end of the season session will be a reflective examination of how you can achieve the goal of zero harm and create a culture of safety. You are on your way, but in this session the inspiring stories of how other organizations have transformed their practices into models of care will further compel you to reflect on your own practices. In this course, not only will you learn more about what it takes to be a high reliability organization, you will end this course, and the series as a whole, with a list of action steps you can take as you travel down the road to patient safety.

Visit C&A’s all-new eClassroom to learn about our latest course offerings.

Jill Ryan

Author Jill Ryan

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