Day 1
8:00-8:30 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 clients (by service/program) with name, address and diagnosis/condition
- High-level organization chart
- Identification of governance membership by background and consumer/non-consumer status, if applicable
- Periodic Performance Review and Plan(s) of Action
- List of eligible contracts (direct services)
- Environment of care management plans
- Policies/procedures for credentialing and assignment of clinical responsibilities
- Performance improvement data
- Infection control data
- Evidence of compliance with Public Information Interview Notification
Orientation to behavioral health care organization
A high-level orientation to the organization (vision, mission, community, etc.)
8:30 - 9:30a.m. Surveyor Planning Meeting
- Review the Priority Focus Process information
- Review the Periodic Performance Review and Plan(s) of Action
- Quick overview of the Statement of Conditions (SOC) and Plans for Improvement (PFI) if applicable
- Review list of eligible contracts
- Review list of current clients
- Quick overview of performance improvement and infection control data
- Select four clients for Tracers
- Finalize agenda activities
9:30 - 11:30 noon Tracer Activity
Tracers will include:
- Observation of Environment of Care issues
- Observation of direct client care, treatment or services
- Observation of medication process (storage or administration), if applicable
- Performance improvement discussion at the staff level
- Review of open clinical/case records
- Staff questions and interviews
- Review of policies as needed
- Education at various points, as applicable
Tracers may include:
- Review of closed clinical case records
- Client interview
- Program/service visits
- Client care, treatment or services visit
- Interdisciplinary team interview, if applicable
11:30 - 12:30 noon Environment of Care Review #1
- Review of management plans
- Review evaluation of emergency plan
- Review system for reporting of accidents, injuries, and safety hazards, identification of any trends, implementation and monitoring of improvement
12:30 - 1:00 p.m. Lunch
1:00 - 2:30 p.m. Tracer Activity
2:30 - 3:30 p.m. Systems Tracer
Discussion with appropriate staff regarding the management of medication, infection control issues, and the use of data for improvement purposes, if applicable.
3:30 - 4:00 p.m. Issue Resolution
4:00 - 4:30 p.m. Surveyor Planning
Day 2
8:00 -9:00 a.m. Environment of Care Review #2
Building tour for Life Safety Code compliance, if applicable
9:00 - 10:00 a.m. Leadership Conference
- Discussion of critical systems analysis exploration - Leadership probes on some of the critical processes
- Review of Periodic Performance Review Plans of Action, if applicable
- Discussion of organization-wide performance improvement activities as appropriate to type and scope of services
10:00 - 12:30 p.m. Tracer Activity
12:30 -1:00 p.m. Lunch
1:00 - 2:00 p.m. Human Resources/Credentials Review
- Selected records to include behavioral health care professionals of interest pertaining to Tracer activities
- Includes contract staff
2:00 - 3:30 p.m. Surveyor Integration of Findings
3:30 - 4:30 p.m. CEO Survey Results Meeting and Exit Conference