YKHC is on a triennial (three year) cycle related to Joint Commission Onsite Surveys. TJC conducted YKHC’s most recent onsite survey in August of 2018. Due to some of the findings, TJC conducted two additional onsite surveys to ensure that YKHC developed and continually monitored the Plans of Correction accepted by TJC.
During the years between the Joint Commission onsite surveys, TJC recommends that organizations conduct Intra-cycle Monitoring (ICM) Surveys (Focused Standards Assessment – FSA). There are three options available from which to choose:
- Attestation that it was completed, but not submitted to The Joint Commission,
- On-site survey with documented findings,or
- On-site survey without documented findings.
Leadership has assigned the responsibility for assisting departments with survey readiness to the Performance Improvement (PI)) Department. This year’s ICM, which is due on August 18, 2019, is a great example of how we use the ICM survey to prepare for the onsite survey.
There are 18 Chapters in the Joint Commission Manual. Each chapter focuses on an area that is related to or could impact patient safety and quality. Some of the chapters are: Environment of Care, Life Safety, Medical Management, Rights and Responsibilities, Performance Improvement, Leadership, etc.
Each chapter is broken down to a number of “standards” or areas of focus for the chapter. Each Standard is further broken down to “Elements of Performance or EP’s”: The EP’s specify the “evidence” (document, log, policy, process, etc.) that proves to TJC that YKHC is meeting the EP and ultimately the Standard.
Department leaders have been assigned to specific Chapters in the Joint Commission (TJC) “Manual. These leaders are responsible for the requirements outlined in the Standards, and the evidence in the EP’s.
Each PI team member is assigned three to four Chapters in the Manual, with the expectation that they be the subject matter expert regarding TJC requirements and evidence needed to meet the Standards. The PI team is currently meeting with their Chapter Leaders to assess compliance with the standards and EP’s as well as to identify gaps in current processes and/or documents.
There are over 1400 EP’s in the Joint Commission Hospital and Behavioral Health Manuals. Updates to the Manuals (the Chapter, Standards, and EP’s) occur approximately twice each year. Staying on top of the changes and making sure that the changes have been implemented is a collaborative process that keeps us busy all year long….
“Making every day Joint Commission Day”.