Our TJC discussion this month centers around two topics. One, The Joint Commission released two new TJC FAQs covering suicide prevention and exit stairwells. And second, we share our Day-One Document advice to better prepare you for an upcoming survey.
New TJC FAQs
The first new FAQ deals with suicide prevention which was posted in the EC and NPSG chapters. It eliminates video monitoring for patients identified at a high-risk for suicide. Instead it mandates direct 1:1 in person supervision.
The second FAQ is in the life safety code chapter. And, it somewhat loosens scoring of extraneous materials in exit stairwells.
The life safety code prohibits storage of anything in exit stairwells that might interfere with departing the building. This can include evacuation sleds, because of the space they take up. However, the new interpretation now permits video cameras and Wi-Fi routers as long as they don’t interfere with egress.
Day-One Document Advice
In the last three months, we discussed our actual observations from Joint Commission surveys identified in reports shared with us. This month we wanted to do something a little different. Instead of issues scored by TJC, these observations are important to the survey process. In fact, they may lead to requirements for improvement in a wide variety of different standards areas. In addition, we quite often see flaws in these areas during consultation visits.
Day One Document List
One problem area is the “Day-One Documents” list. The Joint Commission Survey Activity Guide (SAG), identifies 57 specific documents they want placed in front of the surveyors that very first morning of the survey. Strangely, during mock surveys, we sometimes see organizations view the list as documents the surveyors might ask for.
In reality, there is no optional nature to this request. A blank space instead of a document indicates a lack of readiness or carelessness. Furthermore, it might indicate you do not actually have or meet the requirement. But, all documents should be organized and ready to go.
In fact, these are “first impression documents!” These documents and your first hour orientation, provide the surveyors some insight to how organized or ready you really are.
Another important consideration is how to provide the documents to surveyors. We see three common techniques:
- One huge 3-ring binder with all documents
- Multiple smaller binders with specific content as required
- Individual file folders with all the required content
As you plan how to organize these documents you should consider how large a team will be visiting from TJC. If you have two clinical and one LSC, organizing two large clinical binders and one LSC document binder might work. But, if you have eight clinical surveyors and two LSC surveyors, one huge binder is inadequate. In fact, the surveyors will tear it apart to find the desired content. Furthermore, some content will get misplaced. And, the second or third surveyors to tear into the binder will assume required content is missing.
If you have a large team scheduled, consider using hanging file folders with one topic per folder. And, assess using more than one box of file folders depending on how large your team is.
Assessing Each Document
Also, look at each document your colleagues in the hospital have sent for inclusion with the day-one documents. As you review the content, consider these two essential factors:
- What does this document say about our organization?
- Does it demonstrate we are on top of requirements and managing effectively?
Or, does it say we have problems that appear to be unaddressed or unresolved?
For example, what if required document #20, patient flow data, shows enormous delays in door-to-provider time or decision-to-admit-to-actual-admission time?
You might consider including action plans and evidence of improvements. Plus, prepare for how you might address this issue during the orientation, data use, or leadership sessions.
Pro Tip: Think through what follow up issues this document is going to create due to the information we shared with TJC.
On a related note, consider required document #56. It calls for your certification reports of primary and secondary engineering controls for sterile compounding. You will note that the 2019 day-one document list also says,
“Including any documentation of remediation/retesting conducted based on reported results.”
These documents often identify testing problems, either with the air filtration systems or with microbial contamination. But, the remediation actions are almost always missing. That informs the surveyors that you did not address the problem. Then you are scrambling at the last minute to try and find evidence and prove that you did.
Why Does TJC Ask For A Document?
The second consideration is to look at the day-one list and try to determine why TJC asks for this document. For example, take a simple one like item #1, the hospital license. Why does TJC request this?
Two things come to mind:
- Is the licensure current?
- Is the organization actually licensed as a hospital, thus scheduling a hospital team was appropriate?
Item #13, the list of contracted services, is a little more complex. In this case, the surveyors want to:
- Review your list
- Select one or two clinical contractors to examine the contract for performance expectations
- Look at the evaluation conducted and approved by senior leadership
In addition, surveyors may look to see how complete the list looks. Do they encounter other clinical contractors performing patient care services during tracers that were not listed and presumably not evaluated.
Each and every item on the day-one list is there for a reason. Plus, each one provides clues to the surveyors about your state of compliance and potential follow up activities during tracers.
Patton Healthcare Consulting
Whether it’s Day One Document advice or general survey preparation, we can help. Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services including support developing healthcare’s reporting culture.