Accreditation Surveys Resume

by Expert Advice

Accreditation Surveys Resume

by Expert Advice

by Expert Advice

As accreditation surveys resume and with COVID-19 cases increasing in many states, TJC detailed additional information about how they will handle the process.

Accreditation Surveys Resume

First, TJC will reach out to organizations due for survey to verify that the organization:

  • Ceased emergency operations
  • Stopped using federal waivers
  • Closed surge capacity or sites
  • Has no staff positive test results for 14 days

In addition, they will determine if the organization has any remaining visitor restrictions, and if there are any sites of care in a different state than the main site.

Additional Safety Measures

To resume accreditation surveys, TJC also identified additional safety measures that will take place during the onsite survey. These measures include the following physical distancing steps:

  • Limiting the number of participants at group sessions
  • Minimizing the number of staff traveling throughout the hospital with the surveyor
  • Surveyors traveling independently to remote sites of care
  • Wearing masks and other hospital required PPE. (Surveyors will request the hospital to provide the PPE)

They will also ask organizations to maximize the use of technology. This includes screen sharing or projection of medical records during tracers. Plus, they will use of audio/video conference calls for some attendees at group sessions.

Case Monitoring

In addition, at the June consultant’s forum meeting with TJC, we learned that they are monitoring the number of cases and the new case trend in communities with organizations due for survey. In fact, TJC developed a rather complex formula for analyzing cases. This includes:

  • Per thousand residents within the last two weeks
  • Growth rates in new cases over the past two weeks
  • Percentage of positive tests relative to all tests within the state

Since this involves searching multiple databases, it is not easy to duplicate the TJC analysis.

Further, on June 22nd, TJC posted a revised position statement and FAQs on the resumption of surveys. They use this data to help decide whether to conduct surveys in a particular community. This information integrates the disparate databases for census, new cases, and trend in cases into one site which is a great resource

It also helps to inform how well your community may or may not be doing as compared to elsewhere in the state or nation. At this time, the link is in their June 22 posting (Position Statement) and you should read the entire post. You may also access the site here.

Patton Healthcare Consulting

Patton Healthcare Consulting can help you navigate the new normal. Our new remote consultation “Comprehensive Hybrid Readiness Review” is a hybrid remote/onsite support program. It is designed to assist with assessment and education to meet your needs going forward after this national emergency.

In addition, we understand the need for assistance without disrupting your organization or extensive costs. That’s the specific purpose of this program.  Contact us at (888) PHC-INC1 for more information or email us at


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