On December 2, 2020, the Performance Improvement (PI) department shared the Hospital and Behavioral Health’s progress related to compliance with Joint Commission required documents which is a partial indicator of how ready YKHC would be if the Joint Commission (TJC) showed up for the onsite survey. PI would like to provide another update letting you know where YKHC is today compared with November 2020.
Hospital
Required Documents: 50% compliant – up .08%
Identified Risk Areas: 49% compliant – remained neutral
Behavioral Health
Required Documents: 43% – up 5.2%
Identified Risk Areas: 24% – up 13%
These results are provided to the Senior Leadership Team every other Monday, along with a report on the Departments elements of performance that are either not reviewed or non-compliant.
Onsite Survey Update
YKHC met recently with TJC to review our electronic application (e-App) – an annual application submitted by PI outlining all of the services provided throughout the Corporation and the number of visits for those services. This information allows TJC to determine the number of surveyors needed for the onsite survey.
TJC accepted our application and stated that it would be forwarded on to their scheduling team to determine the date of YKHC’s onsite visit. TJC also accepted YKHC’s avoid dates – the dates that YKHC identifies as not available for surveyors.
Although we don’t know the exact date of the survey, we do know that it will be sometime between January and August of 2021 as the avoid date requests and the 2018 onsite Survey were both in August.
Again, going forward, this truly means that Every Day is Joint Commission Day!
Here are some suggestions that we can all do over the next few months to make sure that we are ready when TJC arrives:
- Locate the Joint Commission Reference Guide that was distributed last year. This spiral bound guide reviews the basics that employees need to know about an onsite survey and survey readiness.
- Check all items in all areas of your department for products with expiration dates. Remove everything that has expired from the department after checking with management.
- Boxes are not allowed to sit on the floor at any time, for any length of time and/or to be stacked 18 inches from the ceiling.
- Keep all walkways in the hospital departments free from clutter. Remove extra equipment, etc. and store them in a storage room.
- Remove outdated books and reference guides, anything over 3 years old, or secure them in a personal locker or personal lockable drawer/cabinet.
- Make sure that all rooms, including storage rooms, are neat and clean and show “Pride of Ownership”.
- Remove all binders containing policies and procedures, with the exception of lab which is under a separate accreditation body which requires binders be present at work stations.
- Learn how to locate policies, procedures, standard work, and forms in Policy Manager.
- Remember: if a document is not in Policy Manager, it doesn’t exist, so if you are storing forms and other documents for use on the document library, on SharePoint, or anywhere outside of Policy Manager the document will not and can not be considered valid or shared with TJC.
- Department Supervisors, Managers, Administrators: review your policies, procedures, and standard work in Policy Manager and make sure that they are up-to-date and accurate as you are ultimately responsible for your department’s necessary documents.
The main things to remember when TJC arrives and you are greeted by a surveyor:
- Stay calm.
- Tell the truth.
- If you don’t remember the answer to a question that you are asked, let the surveyor know that you don’t remember or don’t know, but that you will find out.
- You and you department(s) are the owners not only of the documents, but also of the manuals under which your area(s) fall.
PI appreciates all of your work, Especially during this COVID pandemic. But we can’t forget that we still must meet Joint Commission/CMS requirements.
Questions? Feel free to contact Jaye Marcus-Ledford, LMSW, PI Administrator, at 907-543-6131.