The on-site survey agendas will be developed based on information gathered about the organization from several sources, including the Priority Focus Process, which takes organization-specific presurvey data and converts it into useful information to help the surveyor focus the on-site activity. This allows surveys to be more customized to each organization and structured to spend more time on areas that have been challenges for the organization in the past.
Ambulatory Care Two-Day Survey
Day 1
8:00-9:00 a.m. Opening Conference
Introductions: Joint Commission surveyor and key management staff.
Surveyor planning needs (Surveyor will request the following materials for the Planning Meeting):
- List of active patients (by service) with name, address and diagnosis/procedure
- High-level organization chart
- List of Board of Directors membership by background and consumer/non-consumer status
- List of eligible contracts (direct services)
- Environment of care management plans
- Statement of Conditions (if applicable)
- Policies/procedures for credentialing and privileging
- Performance improvement data· Measures of Success data
- Infection control data
- Evidence of compliance with Public Information Interview Notification
- Orientation to health care organization
- A high-level orientation to the organization (vision, mission, community, etc.)
9:00 - 10:00 a.m. Surveyor Planning Session
- Review the Priority Focus Process information
- Review the Measures of Success from the 18-month Periodic
- Performance Review (re-survey organizations)
- Quick overview of the Statement of Conditions (SOC) and
- Plans for Improvement (PFI)
- Review list of eligible contracts
- Review list of current patients
- Quick overview of performance improvement and infection control data
- Select patients for Tracers
- Finalize agenda activities
10:00 am -12:30 pm Tracer Activity
Tracers will include:
- Observation of Environment of Care issues
- Observation of direct patient care
- Observation of medication process (storage, dispensing, administration, as applicable)
- Performance improvement discussion at the staff level
- Review of open clinical records
- Staff questions and interviews
- Review of policies as needed
- Education at various points, as applicable
Tracers may include:
- Review of closed clinical records
- Patient interview
- Site visits
- Pharmacy visit, as applicable
- Patient care areas (i.e., ambulatory infusion, operating room, examination room)
- Interdisciplinary team interview
12:30 - 1:00 p.m. Lunch
1:00 - 2:30 p.m. Tracer Activity
2: 30 - 3:00 p.m. Surveyor Team Meeting / Planning Session
3:00 - 4:00 p.m. Leadership Session
- Discussion of critical systems analysis exploration - Leadership probes on some of the critical processes
- Discussion of organization-wide performance improvement activities as appropriate to type and scope of services
4:00 - 4:30 p.m. Special Issue Resolution
Day 2
8:00 - 8:30 a.m. Daily Briefing
8:30 - 9:30 a.m. Systems Tracer
- Discussion with appropriate staff regarding the management of medication, infection control issues, and the use of data for improvement purposes.
9:30 - 11:30 a.m. Tracer Activity
11:30 am -12:30 p.m. Environment of Care Session
- Review of management plans
- Review evaluation of emergency plan
- Review system for reporting accidents, injuries, and safety hazards, identification of any trends, implementation and monitoring of improvement
- Building tour for Life Safety Code compliance (if applicable)
12:30 -1:00 p.m. Lunch
1:00 - 2:00 p.m. Human Resources/Credentials Review
- Selected records to include health care professionals of interest pertaining to Tracer activities
- Includes contract staff
2:00 - 3:30 p.m. Surveyor Report Preparation
3:30 - 4:30 p.m. CEO Exit Briefing and Organization Exit Conference