August 05, 2010 | | Comments 1
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Safety surveys for acquired clinics within your hospital system

Q: Our medical system has recently acquired a handful of external medical clinics. We have included these clinics in our annual safety surveys as we have acquired them, treating them as clinical areas needing to be surveyed at least twice annually. I was told yesterday that in the next year we could acquire as many as 30 more clinics. If we acquire that many, it is clear that we will need to change the way we survey for safety.

Are B occupancy facilities, even though they are medical clinics, required to be surveyed by the safety survey team? Do we have to conduct bi-annual surveys of these areas as we do within the hospitals? Are there other models out there that you are aware of for surveying?

A: The thing is, The Joint Commission (TJC) standards don’t differentiate based on occupancy type, but rather utilization, so for areas that are surveyable by TJC (and that’s an important point to keep in mind), hazard safety tours need to occur semi-annually in areas providing services to patients, which is going to be a great big pain in the tuchus if you add 30 sites.

Now I suppose you could request additional resources to cover these extra practices, or at least ask to be able to do an initial assessment of the practices as part of the pre-purchase due diligence process (actually, as I look at your question, you said acquire, which could be different from purchase from a regulatory standpoint).

I think, from a comfort standpoint, you should really push on the pre-survey – you don’t want your organization to get waist deep in this only to find that they’ve got safety violations up to their eyeballs, and as the new “owners,” your organization is on the hook for corrections.

Beyond that, if no additional resources are forthcoming, then the deal has to be that you would coordinate one survey per year and that the other would be a self-survey. While there is a requirement to do twice per year, it doesn’t say that the process for each has to be identical. Perhaps the self-survey is a quick 20-question list and your survey is the more comprehensive of the two; the bottom line is to make sure that folks in the off-sites are appropriately safe — in terms of the environment and in terms of how they manage that environment.

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Steve MacArthur 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 Briefings on Hospital Safety. Contact Steve at

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  1. If your facility is taking on that many clinics, they may want to consider using an accrediting body other than JC for the clinical systems. Accrediting Association of Ambulatory Health Centers (AAAHC) specializes in these systems and are also certified to do CMS inspections for surgical centers and other facilitys that come under CMS.

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