• Skip to main content
  • Skip to header right navigation
  • Skip to site footer
  • (888) PHC-INC1

HBS logo family- Patton

Patton Healthcare Consulting

  • Products & Services
    • Survey Prep & Support
      • Survey Readiness
      • Survey Preparation
      • CMS Compliance Support
      • Patient Safety System Support
      • Joint Commission International
      • Remote Survey Technology
    • Adverse Decision Response & Recovery
    • Disease-Specific Care Support
      • Stroke Certification Assistance
      • Orthopedic Certification Assistance
    • Continuous Accreditation Support (CAS) Program
    • Interim Healthcare Leaders
    • Tracer Team Boot Camp
    • Healthcare Building Solutions
  • About Us
    • About Patton
    • Our Parent Company
    • Patton Principals
    • Patton Professionals
    • Testimonials
    • Patton FAQs
  • Resources
    • Patton Post Newsletter
    • Patton Blog
    • Additional References
  • Client Login (CAS)
  • Careers
  • CONTACT

Day One Document Advice

You are here: Home / Survey Readiness / Day One Document Advice
March 13, 2019
GP sitting in office holding in hands big binder

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.

Document Presentation

Another important consideration is how to provide the documents to surveyors. We see three common techniques:

  1. One huge 3-ring binder with all documents
  2. Multiple smaller binders with specific content as required
  3. 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:

  1. What does this document say about our organization?
  2. 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:

  1. Is the licensure current?
  2. 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.

Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.

Category: Survey ReadinessTag: Joint Commission
Previous Post:Infection word cloud conceptInfection Prevention Frequently Scored Standards
Next Post:Immediate Jeopardy DeterminationThe word "Jeopardy" in a blurred page in a book

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Sidebar

Enter your email address to follow this blog and receive notifications of new posts by email.

Loading

Archives

Categories

  • Company Announcements
  • COVID-19
  • Preliminary Denial of Accreditation
  • Q&A
  • Survey Readiness

Recent Posts

  • When is a History & Physical (H&P) Exam Required?
  • Which Patients Does NPSG 15 Apply To?
  • Safety Data Sheets in the Pharmacy
  • Surgical Tape On Instruments
  • Joint Commission Age-Specific Competencies

© 2021 – 2025 Patton Healthcare Consulting, an HBS Company.  All Rights Reserved

Privacy Policy | Cookie Policy

Manage Cookie Consent
We use cookies to optimize our website and our service.
Functional Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
Manage options Manage services Manage {vendor_count} vendors Read more about these purposes
View preferences
{title} {title} {title}
Manage Cookie Consent
We use cookies to optimize our website and our service.
Functional Always active
The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
Preferences
The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
Statistics
The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
Marketing
The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
Manage options Manage services Manage {vendor_count} vendors Read more about these purposes
View preferences
{title} {title} {title}