RSSAll Entries Tagged With: "changes to survey process"

Why pay full price for the right thing…

…when you can get an approximation for a lot less money!

I’ve been sitting on this particular line of thought for quite some time—long enough for the world to get to a place where having to “make do” is not only the order of the day, but a philosophy that is being endorsed by the various and sundry regulatory folks as work to hold the line on PPE and other operational necessities. It seems almost daily, the hard lines that existed in the compliance world have blurred to the point of vanishing. And while we know that things will eventually return to whatever normal awaits us, there are some indications of what that world might look like (again, looking purely at regulatory compliance as a function of surveys).

While there has been no formal public announcement yet (though I am anticipating something or other in the not too distant future), it seems that something we chatted about almost a year ago is going to manifest itself during surveys conducted by our friends in Chicago to the tune of an additional scheduled survey day, with the intent being the opportunity to really kick the environmental tires (so to speak) in your outpatient locations. As we discussed last year, I believe that there’s the potential for any number of vulnerabilities in the outpatient settings that may not manifest themselves so readily in the hospital setting, but if you look at what has been driving the numbers when it comes to the survey of the physical environment, it is clear that a lot of the same potentials exist—loaded sprinkler heads, issues with door hardware, gaps in inspection, testing and maintenance activities, depending on the environment, even air pressure relationships, and the management of temperature and humidity can be in the mix. The cynic in me is quite certain that there is no surprise in moving further afield with the survey process when it comes to generating findings—think of how much stuff they found in hospitals, where we exercise the most “control”! At any rate, I’m sure we’ll be getting the official word soon, but I’ve been thinking about what this is all gonna look like post-COVID and I think this is an important piece to be thinking about in terms of preparation.

In closing for this week. I wanted to share a piece on inspirational quotes. I personally don’t hate inspirational quotes as a going concern, but I hadn’t run into to a few of these before, so I figure it can’t hurt to share with the group.

Hope you all are safe and (reasonably) sane—you’ve got this!

On your marks, get set, sweat!

But hopefully not a Billy Idol kind of sweat…

Our friends in Chicago are once again tweaking the survey process, with the result being less time for surveyors to wait for organizations to muster their troops at the outset and pretty much no time at all before they are out and about doing tracers. Basically, what used to be the surveyor planning session in the morning of the first survey day is now being flipped and combined with the special issue resolution session at the end of the day. For organizations to adapt their process to the changes, folks should be prepared to do the following:

  • Prompt alert of/to the leadership team of any on-site survey to facilitate their availability for a prompt opening conference (I can’t think of too many folks who are not already doing this)
  • Prepare all required documentation and deliver those documents to the survey team immediately after the team is escorted to their “base” (the list of required documents is available in the Survey Activity Guide, although it begs the question as to whether this includes the life safety documentation…)
  • Gather the scribes together so they are ready to hit the pavement as soon as the (ever-so-brief) opening conference is completed

Somehow I think this may all tie across with the folks from CMS accompanying the Joint Commission folks as part of the validation process—anyone who has dealt with a state and/or CMS survey will tell you, there’s not a lot of time (or indeed, inclination) for pleasantries. The job of being prickly requires a lot of inflexibility, which does seem to be the hallmark of the current survey process.

These changes to the survey process are effective March 2020.

The song changes and yet remains the same…

There was a time when The Joint Commission actually seemed to be encouraging folks to fully engage with the clarification process in all its bountiful goodness. And I certainly hope that folks have been using that process to ensure that they don’t (or didn’t) have to “fix” processes, etc., that might not have been absolutely perfect in execution, but were not, by any stretch of the imagination, broken. But now, it appears that the bounty is going to be somewhat less bountiful as TJC has announced changes to the process, effective January 1, 2017. Please forgive my conspiracy theorist take on this, but it does seem that the new order in the accreditation world appears to lend itself to survey reports that will be increasing in the number of findings, rather than a reduction—and I am shocked! Okay, perhaps “shocked” is a tad hyperbolic. BTW, in a new Advocacy Alert to members, it appears that ASHE has come to the same conclusion, so it’s not just me…hoorah!

And so, the changes:


  • Any required documents that are not available at the time of survey will no longer be eligible for the clarification process (basically, the vendor ate my homework). It is important for everyone to have a very clear understanding of what TJC means by “required documents”—there is a list on your organization’s Joint Commission extranet site. My advice, if you have not already done so, is to immediately coordinate the download of that list with your organization’s survey coordinator (or whoever holds the keys to accessing that information—it may even be you!) and start formulating a process for making sure that those documents are maintained in as current a fashion as possible. And make sure your vendors are very, very clear on how much time they have to provide you with the documentation, as well as letting you know ASAP whether you have any deficiencies/discrepancies to manage—that 60-day correction window can close awfully quickly!
  • While I never really liked to employ this strategy, there were times when you could use clerical errors in the survey document to have things removed from the survey report. Areas that were misidentified on the report (non-existent to your facility; not apropos to the cited finding, for example, identification of a rated door or wall where there is none, etc.) or perhaps the location of the finding was so vague as to be impossible to identify—these have all been used successfully, but (apparently) no more. Now whether this means that there will be more in-depth discussions with the survey team as they prepare the report is unknown at this time, but even if one slips by (and I can tell you, the survey reports in general are much more exact—and exacting—in their description of the deficiencies and their locations), it won’t be enough to remove it from the report (though it could make your ESC submittal a bit more challenging if you can’t tell what it is or where it is).
  • The other piece of this is, with the removal of “C” Elements of Performance, you can no longer go the audit route to demonstrate that you were in substantial compliance at the time of survey. So now, effectively, everything is being measured against “perfection” (son of a…); miss one month’s check on a single fire extinguisher and—boom—finding! One rated door that doesn’t latch? Boom—finding! One sprinkler head with dust or a missing escutcheon? Boom—finding! And, as we touched on last week, it’s not just your primary location (aka, “the hospital”) that’s in play—you have got to be able to account for all those pesky little care sites, even the ones for which you are not specifically providing services. Say, for example, the landlord at one of your off-sites is responsible for doing the fire extinguisher checks; if something is missed (and hey, what’s then likelihood of that happening…), then you are vulnerable for a finding. So, unless you are prepared to be absolutely, positively perfect, you’d best be making sure that your organization’s leadership understands that the new survey reality is not likely to be very pretty.

I would like nothing better than to tell you that with the leadership change in Washington there will be a loosening of the regulatory death grip that is today’s reality, but somehow I don’t think that’s gonna happen…