(Donna) Hello, and thank you for allowing us
to spend some time with you
for Questions and Answers with The Joint Commission,
Navigating the Most Common First Survey Challenges
for Nursing Care Center Accreditation.
My name is Donna Rutkowski, and I'll be your moderator today.
Before we get started,
I'll take a quick minute here to tell you how to participate.
You should see a control panel on your computer desktop
in the upper right corner of your screen.
In that control panel, you'll see a pane for questions
where you can submit a question any time during the webinar.
Today, we have some of our Nursing Care Center experts with us
who will be presenting answers to your submitted questions
regarding what to expect
during your first nursing care center survey with The Joint Commission.
We hope you enjoyed our pre-recorded webinar
about lessons learned from previous initial nursing care surveys,
and that viewing it brought you to us today.
Today, we'll go through the questions that you've submitted
about standards, the survey process, environment of care, infection control,
and basic accreditation operations.
We'll also briefly touch on a resource
we want to make sure you're aware of, once you become accredited,
that provides information about observations
that are learned during surveys.
Please submit additional questions you may have
by typing them into the the Questions pane of your control panel.
We will send out an email with today's presentation
and the recording later this week.
With that, I'm going to turn it over to our first presenter.
Director Sylvia Garcia Houchins, who will start our presentation
with answers to questions you submitted about infection control.
(Sylvia) Thank you, Donna.
The standards tell us to develop an infection control plan.
How do we start? Is there a template or resource to help?
We don't have a large staff,
and we don't know where to begin with the standard.
Next slide, please.
Here, what I've done is given you a basic outline
for developing your infection control plan.
The Joint Commission does not have a specific format
that we would expect you to follow,
just that you have the information that we need you to have,
and you need to have
to determine what you're doing from an infection control standpoint
and explain it.
The first step, whenever you are planning anything,
is to think about what care, or treatment, and services do you provide,
and what are the possible related risks?
That's what I've done here.
I always like to tell people,
what's your plan for building your kitchen?
Well, the first thing you do is try to figure out what you need.
Or what are you doing in that kitchen?
It's really the same thing for your infection control plan.
Let's think about some of the things
that might present an infection control risk.
First one is what kind of basic care do you provide,
and then what are the risks associated?
For example,
you're going to be feeding your residents while they are in your care.
So, if you don't maintain safe food temperature,
or you have poor sanitation,
or you don't follow your health department food sanitation rules,
that could create an infection control risk,
because people could get a foodborne illness.
If you're bathing a patient,
there could be a risk of exposure to waterborne pathogens,
if you don't have a water management program,
or if you're using common equipment to do bathing with:
everybody's using the same back scrubber, the same brush--
that could lead to transmission of microorganisms.
As you go through the care treatment and services that you provide,
you want to list those things you do for patients,
and then, is there an infection risk with those?
Do you use invasive devices, are there medications?
Are there risks of missing aseptic technique,
or using a multi-dose vial?
Thinking it's a multi-dose vial, using a single-dose vial.
Have you seen that before?
How about your disposal of syringes?
Do you have sharps disposal containers so your staff don't get injured?
All of that, once you identify your care treatment and services,
and you identify the potential risks,
then, you evaluate how you're doing to address those risks.
If you have great kitchen staff, and they are maintaining the temperatures,
and the sanitation is great,
then, it's not a big infection control risk,
but something else might be.
So you evaluate the risk against what you're doing,
and then, you prioritize what you think might need more work.
Then, once you've identified what might need more work,
that's when you start your planning.
What am I going to do
to reduce the risk that I've identified.
And then, that's what you write into your plan.
So, I hope that helps you get just some nuts and bolts down.
It seems like it's overwhelming sometimes,
but it's really following those basic steps.
What am I doing for patients?
What is the risk of infection-related to what I'm doing for patients?
What am I doing well,
and what do I need some help with or need a little bit of work on?
And then for the things that I need a little work on,
what am I going to do to improve those?
Next slide, please.
We're getting conflicting information about what to do with masks etc.
Is there a way to find out what Joint Commission's expectations are
when they come in for the first time?
Next slide, please.
The Joint Commission surveyors are following the same approach
when they are looking at compliance
with any infection control-related standard.
We follow this hierarchical approach, and you can read more about it.
If you go to the Joint Commission Infection Control webpage,
we actually provide a copy of the article that explains this.
What we do is we start with the top:
in your location that you are at, is there a rule or regulation
that would say you needed to wear a mask?
Because we expect our organizations to follow law and regulation.
If you are a deemed organization, which we don't do deeming for NCC,
but if you are deemed organization,
what does CMS expect at the time?
Right now, CMS has really not been prescriptive about masks.
So we would expect you to have looked
at what they say is to look at the applicable guidelines
and to apply accordingly.
We would expect you to have done that.
There aren't a lot of manufacturers' instructions for you.
They might talk about use of masks and how to use the masks,
but nothing that's going to direct you on what you need to do.
And then, finally, we have Evidence-Based Guidelines and the National standards.
We would expect accredited organizations to at least have looked and considered
what evidence-based guidelines and national standards are out there
that would apply?
in this case, CDC has put out quite a bit of information about use of masks
in the nursing care setting.
But again, we would expect you to follow what your organization
is at minimum required to by law and regulation.
Now, I would like to say that some states or localities,
have some very specific requirements for masks in NCC ,
based on what's happening in local conditions.
They may not mirror what your state as a whole is doing,
but the Joint Commission is seeing routinely or with CMS requirements are.
So please, if you have any questions
as to whether you need to be wearing a mask or not,
we recommend that you contact your local health authorities
so that you can clarify those requirements.
And, really, during survey,
if you are wearing masks or you're not wearing masks,
the surveyors really going to be saying,
what's your process?
How did you decide to do what you are doing?
And does it follow this process?
Next slide, please.
How do you suggest cleaning and storing reusable face shields?
The default for any cleaning and disinfection
is always going to be: follow manufacturer's instructions.
So, if the surveyor asks you, how do you clean something,
they're expecting you to say,
"We follow manufacturer's instructions for use,"
and then you can demonstrate that you are following them.
Do you have a copy of the manufacturer's instructions for use?
But we know with the pandemic,
a lot of organizations had to scramble to get this type of equipment.
Some of them had it donated.
They may not have manufacturer's instructions for use.
The alternative here would be to follow guidance.
The one that we go to the most often is the CDC.
And CDC has provided guidance,
If you don't have manufacturer's instructions for use.
Their assumption is:
if you don't have manufacturer's instructions for use,
for cleaning and storing reusable face shields,
what you're calling "reusable face shield,"
you don't have instructions to clean it.
They would classify it as a single-use facial.
Now, that doesn't mean you can only use it one time,
What their recommendation is
then assign that face shield to the same person,
and it becomes their reusable face shield,
but you're not moving it from employee to employee.
If that is the case,
they have on their website a recommendation
that you use a soap and water cleaning if it needs it,
if it's visibly soiled,
and then you disinfect with an appropriate wipe.
You may have to do a little bit of checking
to make sure that it doesn't cloud whatever the material is.
And then wiping the outside.
The inside, you need to be careful of,
because disinfectants may cause some fumes
to be released for a little bit,
and depending on the plastic, may create an issue.
So they recommend clean the outside.
And if it's being used for one person immediately--
you are're going to use it, wipe it, and then you're going to put it back on.
You may not want to clean the inside at that point.
But before you store it, wipe the whole thing down
and then store appropriately for that individual.
I hope that answers your question.
I'm now going to... Next slide.
I'm now going to turn this over to Beverly Belton,
who is our Field Director for Nursing Care Centers.
(Beverly) Thank you very much, Sylvia,
and good afternoon everybody.
Next slide, please.
The first question is: What role does an Administrator serve
in The Joint Commission accreditation survey process.
The first thing to remember
is that The Joint Commission accreditation survey process
is not just one single event.
It doesn't just take place when the surveyors are actually on site.
The survey actually begins from the moment that you decide
to become Joint Commission accredited,
where the Administrator along with other members of the leadership,
the onsite leadership team,
work together to understand what our standards are
and to prepare the organization
for their journey to accreditation.
And once the process is over,
the Administrator is responsible for working with that same group
to ensure that any responses or follow-up takes place,
and that you are able to maintain the gains
that you get from the accreditation process.
When the surveyor is on site,
the Administrator along with the entire onsite leadership team
is an important part of the survey process,
as you all play an important role in the establishment and sustainment
of quality and safety throughout the facility.
And, as you know, The Joint Commission Standards
support the provision of safe quality care
in the healthcare organizations across the continuum.
So, when the surveyor arrives on site,
one of the first things they'll do
is meet with the Administrator
or whichever leader is on site at the time.
It usually is the Administrator
and/or the Administrator and the Director of Nursing,
and they will orient themselves to your current state.
If there's anything special going on at your nursing care center,
this would be the opportunity to have that discussion with the surveyor.
And this occurs during the opening session,
when the surveyor's also reviewing with you the agenda.
The administrator should definitely be present during that session.
There are five other key points,
when it's important for the Administrator to be present:
the opening session, which we've already talked about;
the life safety building tour
when the surveyor and your Maintenance Director
are literally going through your building
and looking at potential risks that exist there;
the leadership and data use session;
the daily briefings;
and also the exit conference.
In addition to those, for your first Joint Commission survey,
it would be useful for the Administrator
to also be present during the other system tracers
to get a better idea of the overall assessment process.
Next slide, please.
The next question:
When surveyors walk in, will they ask immediately
about staff privileging,
or does that fall elsewhere during their time with us?
And also, what do we need to have ready to address that?
The answer to the first part of this question is "no."
When the surveyor walks in,
they'll be focused on really collaborating with you
to provide a meaningful survey.
And, as I mentioned earlier,
they will be looking to understand your current state,
what's going on in your building,
what are some of the challenges you're facing-- those kinds of things.
And they will review the agenda with you.
The staff competence and the provider privileging session
is usually scheduled to take place
on day two of the survey.
At some point during day one,
the surveyor will actually sit down with you and give you a list
of the individuals whose files they will want to review
during the competence
and credentialing and privileging sessions.
As far as what you need to have ready,
they will also share that with you,
but if you take a look at the Human Resources chapter
of your Accreditation Manual,
it tells you exactly the things that the surveyor will be reviewing
during those sessions.
Next slide, please.
The next two questions deal with staffing,
and I'm going to answer them together.
The first question is: We're short-staffed for multiple reasons,
is there anything you can share regarding how to handle this issue,
and do we address that with the surveyors when we meet them?
Next slide, please.
The second question is: What can we do to recover
from poor staffing due to COVID-19 causing health care challenges
and may attribute to unintentional poor outcomes to patients?
First, I want to reassure you
that we are well aware of the staffing challenges
that are going on in nursing homes
and also other portions of the healthcare continuum.
And our surveyors are very sensitive to this
when they walk into your facilities
and will work with you
to integrate your current state
into the survey process.
So, if because of staffing you don't have someone available
to review a patient record with the surveyor at 9:00 in the morning,
but it will work better for you
that we did it at 10:00,
then the surveyors will actually accommodate
those kinds of requests as well.
It's important to be open and honest with the surveyor about your current state
because we want to make sure
that you have a meaningful collaborative survey.
But we also want to do it in a way
that we're being mindful of what your current status is.
Quality and safety is important
no matter what's going on in the facility,
but the way we evaluate and assess our standards,
we can make adjustments
to the timing to accommodate your staffing needs.
And also the basic question
around what we can do to address our staffing needs.
One of the questions that you should ask yourselves
is how can I make adjustments
in the model of care that I'm currently using,
based on a staffing that I have available,
and still meet the needs of the residents that are in my facility.
What we're looking at is not necessarily your numbers.
We're looking at the assessment of our standards
and how your're meeting those.
There is lots of research available in the literature
and from many national organizations
that are looking very closely at the hows and whys of staffing in nursing homes,
and those are readily available to you.
Next slide, please.
Is The Joint Commission survey focused on COVID-19 at this time?
No, our survey process was never focused on COVID-19.
However, as COVID became more prominent
and, of course, hit nursing homes very hard,
we were very mindful of the experience of nursing homes
that were dealing with COVID-19 residents and also staff
who were being impacted.
So we made adjustments to our survey process
in recognition of the hard work that you were doing
and you continue to do in that environment.
The COVID-19 is actually an infection control issue.
And if you've had a chance to take a look at our manual,
and as you've heard Sylvia referred to a moment ago,
we have an entire chapter in our Accreditation Manual,
dedicated to infection control.
So whether we're in the middle of a pandemic,
or whether we are out of the pandemic and in the endemic phase,
we are going to evaluate your compliance with our Infection Control Standards,
and that is across your facility, not just related to one specific illness.
Next slide, please.
What are the best resources for staying abreast
of the rapidly changing regulations and standards
that are going to affect our survey?
The first thing to remember
is that The Joint Commission is an accreditor, not a regulator.
So, the best way to stay abreast
of The Joint Commission Accreditation Standards
is to access all of the resources that you will have available to you
through The Joint Commission Connect site
and also prior to becoming a Joint Commission accredited facility
or going through the process.
You can access our public website
that has a variety of updates, useful tools,
frequently asked questions and other resources
that are useful to helping you stay abreast
of our accreditation standards.
When it comes to regulations, again,
remembering that The Joint Commission is not a regulator,
but you can follow your state
and/or local health department website or social media
to keep up with what's going on.
Also, since most of you receive a state and CMS surveys as well,
you can follow the CMS website,
and they do a National Nursing Stakeholder Call
several times a year, usually quarterly.
And the most recent one was actually done on February the 2nd,
and their focus was on COVID vaccines.
They included a lot of really good information useful for you,
and they also included... highlighted a facility
that had done a really great job
of getting a 99% vaccine rate
amongst their employees,
and their resident rate was equally as high.
So lots of good information there.
And then also, although, again,
it's not the regulator, the regulators,
and also, as an accredotor, deferred to the CDC
as a source of information
and evidence-based recommendations.
So, following the CDC website,
and there is a section that's specific to nursing homes.
Those are all great resources that you can follow
to stay abreast of changes.
And if we can go to the next slide.
I'd like to thank you for your attention and turn over the mic
to my colleague Edward Smith, from our Standards Interpretation Group.
(Edward) Thank you Beverly. Thank you so much.
Well, good morning to some, good afternoon to others.
My name's Edward Smith,
and I'm from Standards Interpretation and happy to answer some questions today.
So, first one: Will The Joint Commission
utilize the same standards used on the acute care setting
to survey nursing homes?
Well, the Nursing Care Manual is customized to your setting.
There is overlap between Acute Care Standards and Skilled Care Standards,
but only where it's appropriate,
such as maybe some of the National Patient Safety Goals.
And even though,
there are several differences and expectations,
based on the environment.
What you don't need to worry about
are standards that aren't relevant to your services.
These standards are applied
and designed for your organization's Path to Zero Harm.
Now, the other thing you might want to consider
is applying for Acute Care certification.
If you provide care to an acute care population,
this may be a great opportunity for you.
It provides an excellent framework
for safe and quality care
of acute patients in a skilled environment,
and it also provides an opportunity
to distinguish yourself from your peers and ensure safety.
All those can be done on the same survey.
So, if it's something that you're interested in,
then I would definitely talk to your Account Executive.
Okay, next slide, please.
Can you please describe if we have to adhere
to waived testing standards at our facility?
How do we know if they apply to us?
If you perform tests like the iSTAT, glucometry, stool occult, urine dipstick,
then they're applicable to you.
Because those are the most common waived tests,
tests that are performed in skilled facilities.
If you do prefer those,
then the Waived Testing Standards would apply,
and these standards provide a wonderful framework
on how to navigate waive testing safely.
A few pointers with testing management:
one, confirm your CLIA waivers up todate
and the preferences that correct CLIA Director.
Two, confirm your device is approved for professional and multi-patient use,
not single patient use.
Three, determine how often and in what manner
the monitor needs to be cleaned.
Four, review documentation for device maintenance
and confirm the documentation is complete.
This could also include quality control testing per manufacturer guidelines.
And bear in mine, that we all know that the actual needlestick
is never reused,
but the actual injection device is also single-use per patient,
cannot be used for multiple patients per CDC.
Lastly, if you get involved in waive testing
and it becomes complicated,
The Joint Commission still has that covered.
We have a certain laboratories that are at our availability right here,
in Standards Interpretation,
that can answer almost any question
that comes up in regards to waived testing.
Next, slide, please.
When we have a question about a standard,
how do we get the answer that is best for our nursing care center?
Well, my department, Standards Interpretation--
we're dedicated to helping you with those questions,
For customized answers,
please, go to our website www.jointcommission.org,
and directly right there, in the middle of the page,
is a link to submit questions to our department.
If a conversation is better from your needs,
there's an option to request a discussion.
You can even request a time and date that works for your schedule.
In addition to these individual communications,
Joint Commission has set up a wealth of knowledge in our FAQ's.
And we provide publication, such as Perspectives,
and then produce blogs nowadays.
So, there are numerous resources,
and these resources demonstrate our commitment to our customers.
Next slide, please.
Are there special standards just for COVID
that are not in the manual that we're using.
No, there are no standards that are specific to COVID.
That said, the Comprehensive Infection Control chapter
provides the necessary framework
for a competent infection control program that will successfully address COVID.
A well-prepared plan will adapt
to any infection control emergency or outbreak.
As Beverly said, we've never surveyed to COVID.
We've surveyed to your plan, and we've seen how you've addressed COVID,
utilizing a process as Sylvia referenced,
starting going to that ladder process
to make sure you capture everything that you need for a comprehensive program.
I would recommend, again, our website www.jointcommission.org,
and then, on top of the page, very top, there is a gold bar,
there's a link leading to a host of resources.
We've developed this to support your nursing care center needs.
Be sure to consider applicable CDC recommendations,
as well as those imposed by other authorities
such as specific state requirements and CMS.
There is also another requirement in the Infection Control Manual
that's very important,
and that is to identify an individual
that as the background authority--
the person who's going to run your infection control program.
I would be very critical
about who is going to fulfill this responsibility.
It is a lot of responsibility.
It's okay for somebody to grow into that role,
but they need a seasoned mentor, or they need to come in seasoned.
But either way,
we need somebody in your organization
or you'll need somebody in your organization
to provide the support you'll need to navigate
the most recent waters.
It can be homegrown.
Outsourcing-- it's not necessarily required to outsource,
but having the knowledge-based-- it is important.
So having a person, the right person in that role is important.
Okay. Next, slide.
Will we have Patient Safety Goals Standards every year
or just when we're going through actual survey days?
Once again, similar to have Beverly mentioned.
Our accreditation is not about any one point in time,
but rather processes that goes over time to ensure safety.
So, the National Patient Safety Goals are not intermittent processes,
rather ongoing practices,
including the establishment and revising of goals.
National Patient Safety Goals that require establishing goal,
such as fall prevention and hand hygiene.
Manage these goals is like any other PI program.
A baseline is initiated or established,
goal's identified,
plan is developed and implemented.
And lastly, a re-evaluation to determine if the goal was achieved.
If not-- re-evaluate the plan.
If goal is achieved, elevate the goal.
The timeframe for achieving these goals are determined by your organization.
Next slide, please.
How will an initial organization be surveyed
against the National Patient Safety Goals?
We review all the ones that are applicable
to nursing care centers.
We actually have a process where we must confirm
that you're in compliance with all those,
which is the only requirement that a certain set of standards
are verified during a survey.
So, yes, we will review these.
But understand these may be very new, and that's okay.
We're looking to see that all necessary processes are in place
and have been implemented
to satisfy the National Patient Safety Goals.
That said, there are some elements of performance
that aren't usually achieved on an initial survey,
such as evaluating the full program.
But, the full program should have an outlined evaluation process
and a timeframe for conducting the evaluation.
So you could see where you need to have the complete component,
but some pieces of it aren't achievable at this point.
All right.
Next slide.
Are there specific standards that are geared
just for our medical director to follow and comply with?
Yes, in the Human Resource chapter,
there are requirements related to credentialing and privileging.
The medical director is also assigned responsibility
for overseeing the care and services to all the patients.
And in addition, they also participate in policies
regarding emergency medication management.
Now, there isn't a specific section in the manual titled "medical director."
So how was I able to obtain that information?
Using the same tool that we're going to provide to you: the E-dition.
It's an electronic version of the manual.
I was able to go in there, put in the search word "director,"
it searched the entire manual
and brought up all those that would reference "medical director."
Very easy. I love that piece of software.
I use it every day and I suspect it will be very helpful to you as well.
That being it.
Next slide, please.
That's all for me.
Everyone, thank you for your time today.
And now I'll pass the mic on to my good colleague, Marissa Voelkel.
(Marissa) Thank you, Ed. Next slide.
The question: Of the three chapters for the physical environment,
is the same amount of time spent on them during the survey,
or should we expect certain areas to have more time than others?
The way that the survey actually works is you will have a surveyor come in.
They will want to look at documentation
for your inspection, testing, and maintenance,
on the various components in your utility systems,
your fire systems and so forth.
They will also want to do a walk around through your facilities.
They will be looking at certain rooms, like hazard rooms,
they'll look at the systems that you have in place.
If you have a fire alarm panel-- they'll look at that.
If you don't, they'll check tags on fire extinguishers, that kind of thing,
exit signage and so forth.
It's kind of a mix and happens almost simultaneously.
As the surveyor is walking around, they may ask questions
when they see things that prompt those questions,
such as with Emergency Management, they may ask someone,
"What would you do in case of a fire?"
and just see what the staff says and make sure
that that is coinciding with whatever you have in policy
or in your plans.
So, a lot of time is spent on the tour,
but the tour is not only looking at physical environment things,
but doing tracers and talking to the staff,
and they may have some clinical that they do at the same time.
I know that it's a vague answer.
The time spent in your documentation
is going to be more time consuming, for your inspections, testing,
and maintenance record keeping, and your Emergency Management documents.
It may seem like the surveyor's spending more time walking around.
It may seem like they're looking at the documents more
but they all work hand-in-hand.
Next slide.
Will there be new regulations released pertaining to disaster preparedness?
At this time, there is not.
The current chapter that we have for emergency management
is the chapter that you should follow
under the NCC Manual for disaster preparedness.
The way our process works
is we look at what's going on in the world,
we take lessons learned,
we are at work with Center for Medicaid and Medicare CMS.
And we gauge our standards to that.
So there are new standards.
You may have heard that coming out
for hospitals and critical access hospitals,
but they do not pertain to NCCs at this time.
Next slide.
What is the expectation of how fire drills are to be done
while adhering to social distancing?
Well, there are two ways to handle this.
The first is, there is currently a CMS blanket waiver
that is available to help your organizations.
It's called the 1135 waiver.
We actually have a standard to ensure
that you have a process for the 1135 waiver.
If you just look it up online, you will find it in a PDF form.
And one of the provisions of that waiver is fire drills.
You still have to run the fire drills.
You still need to educate the staff and make sure they know their roles
during a fire drill.
The only thing that it
allows you to not do is congregate.
So if you are in an area in which congregating would be difficult
or against your local authority having jurisdiction,
then you can modify your fire drills
to be more educational
and in the spot where the people are working.
But keep in mind, the surveyors are going to be walking around.
So if staff are congregating, say going to a cafeteria
or a large group gathering,
and then it is stated that you're not gathering for fire drills,
there's an inconsistency there.
Ensure that you're doing that.
The other way that the fire drills can be handled,
otherwise, the way that they're required to be handled any other time,
is to hold them regularly and then just explain to your staff
that with any fire drill,
they only need to send the people that are available at the time.
Meaning, we don't want to disrupt patient care.
So we're not asking you, if you run a fire drill,
to have everybody stop what they're doing
and congregate together.
Only those that are not directly involved with patient care
should participate.
And that will limit your numbers a little bit as well.
And have them follow the social distancing rules,
wherever they would go--
whether they go outside or they go to a lobby or so forth.
Next question.
Can you explain what are the most frequent problems that occur
when trying to meet the emergency preparedness standards?
Some of the most frequent issues that come up
are just not having things documented.
If there is an EP that says you have a written plan,
please have a written plan.
If there's an EP that says there's annual reviews,
or quarterly reviews,
or that a certain organ, a part of your organization,
such as senior leaders have reviewed something,
have some method of documentation for that.
People will have their emergency drills and say it happened on this date.
The staff can talk about it, but there's nothing in writing.
So go back to the old clinical adage: "If it's not documented, it's not done."
And that holds very true for emergency preparedness.
The other big part with emergency preparedness
is train your staff.
If you have procedures for a fire drill,
or if you live in an area
that has severe weather like tornadoes or hurricanes,
have procedures for those
based off your hazard vulnerability analysis
and what are your highest risks,
and make sure your staff know what to do.
If you have a three-page policy or plan,
they don't need to know every single step,
but when the alarm goes off,
or when the sound comes out, there's severe weather,
please, activate the plan--
they should know what to do immediately and be able to protect themselves
and the patients or residents.
Those are the biggest things that we see with Emergency Management,
just not having all of those EPs answered,
or having a document for the ones that require something in writing
Next slide.
The topic of fire extinguishers and unblocked exits
comes up with our staff frequently.
Can we narrow what the Life Safety Code Standards are
that apply to these for your first time?
Well, the long and the short is:
fire extinguishers, if you have manual pools,
anything that is going to help extinguish a fire
needs to be unobstructed,
you need to be able to easily get to it.
Often what surveyors see is somebody pushed a wheelchair,
or a stretcher,
or a chair, sitting chair in front of a fire extinguisher,
or they've been mounted behind doors
that usually stay open.
Those will be observations
because we need to be able to get to that equipment
in the emergent case of a fire rapidly and unobstructed.
The same kind of goes with unblocked exits.
The rule of thumb is:
if you're standing in a hallway or in a space and you look up,
and you see an exit sign,
that is an Exit Corridor, generally speaking.
Now, the Life Safety Code drawings will be reviewed
because that is not an absolute statement,
but that is the first rule of thumb-- look for the exit signs.
And if it is an Egress Corridor and Exit Corridor,
then we expect it to be unblocked and not be an obstacle course to get out.
If you just imagine if the room is smoke-filled,
or the hallway is smoke-filled,
how are you going to get out and not bump over things?
So keeping them clear frequently is how to handle that.
We understand that there are short times
that you may have a wheelchair
because you're putting somebody in a room,
or pulling them out to go somewhere,
or there might be a cart because you're serving a meal--
that's all understandable.
The rule of thumb generally is:
if it's been there more than 30 minutes, it's now considered storage.
Next slide.
And now I'm going to turn it over to my colleague, Allison Nicholas.
(Allison) Hi, and thank you so much, and good afternoon.
Will my facility survey be announced or will the surveyors just show up?
For all of our NCC re-surveys, they are all unannounced surveys.
However, organizations that are going
through their first accreditation survey with Joint Commission
will receive a 30-day notification prior to the scheduled event.
We do and continue to encourage organizations
to check your action at site daily,
specifically under the notification of scheduled events on the left-hand rail,
for updates on your scheduled survey.
On the morning of your scheduled event,
the notification of your scheduled survey will post by 7:30 a.m. local time,
and that will also note that the event has been scheduled
along with the biography of your surveyor.
The notification on the extranet site
does serve as your official notice of the event,
but this is also followed by an official email,
sent to both the CEO and primary accreditation contact.
To ensure that all parties are receiving that notification,
we do ask that these contacts continue to stay up to date.
Next slide, please.
Once we get our application in, how long before we have an actual survey?
Once we receive an application and deposit,
we will and do expect your organization
to have a call from your Account Executive within five business days
to review that initial application
and to confirm your organization's ready date.
Once we've confirmed that ready date for your initial organization,
you will receive a 30-day notification as we discussed in the last slide.
All initials do retain the option of waiving your 30-day notice,
in which case you would get in the scheduling queue
just a little bit earlier,
provided that your organization is in an area that we deem safe to travel.
Next slide, please.
Who in our organization will get the information
that surveyors are in our facility on the day of survey?
The notification for survey events, as we discussed earlier,
are available on the extranet site,
but these are specific to the Administrator users
on the extranet site,
unless otherwise indicated on the security tab.
Both the CEO and Primary Accreditation contacts
receive that email notification,
and they are considered Administrative users.
Again, we do encourage organizations to ensure that the primary contact
and CEO contact are up to date.
This helps to ensure any type of onsite issues
or any missed notifications,
because these do serve as that primary means of communication.
Next slide, please.
Are we allowed to request certain weeks or days
when we don't want the survey to occur?
The Joint Commission observes additional holidays
that can be located in the application specifically on tab six.
It's going to show to your organization as a blue box on the calendar.
In addition, we do allot organizations up to 15 additional avoid dates,
which is going to help organizations to navigate
around scheduled conferences, vacations,
or other time planned away from the office.
We will make every reasonable effort to accommodate an avoid date.
However, we do reserve the right to conduct a survey
during the avoid period.
Please also note that we may not honor every single avoid date,
if it's clustered together
or really, really close to the accreditation cycle.
We will take a look at that and see whether or not
it's unreasonably narrowing the period of time
in which schedulers can efficiently accommodate
the unannounced survey process.
Now, again, for initials, you'll get the 30-day notification.
And then for organizations who are applying as re-surveys,
we are not accepting additional avoid dates
for organizations that are past due,
but we do encourage all organizations to submit up to the 15 avoid days
in the current existing application.
Next slide, please.
After the survey time is over, what will happen next?
Do you contact us and say this is how we did?
If an organization's left with a preliminary report,
once the organization leaves the facility,
and once the report has been reviewed by Central office,
an official survey report will be posted to your organization's extranet site.
From there, you're going to have access
to the requirements for improvements or RFI's,
which are going to be plotted on the SAFER Matrix
according to the risk level of the finding.
Organizations are expected to respond to the RFI's
through the Evidence of Standard Compliance form,
which is located on the extranet site,
in the identified timeframe
in order to render your accreditation decision.
Next slide.
And with that, I would like to hand this off
to my colleague, Brette Tschurtz, please.
(Brette) Thanks, Allie. Hi, everybody,
As others have mentioned,
there are a lot of resources available to help accredited organizations
both prepare for survey
and to help with the ongoing accreditation activities.
One of the resources I wanted to focus on today
is what we call the Heads Up Report.
Thank you.
In the Department of Research, which is where I am,
one of the things that we do is to continually monitor scoring patterns
to see where organizations might be struggling,
or where more clarity might be needed.
And after looking at all this data
and seeing certain standards continuing to make the list
of frequently scored or often cited standards,
we decided it would be helpful to create a resource
that specifically targets both those frequently scored standards
and those that are most likely to have an impact on quality and safety.
So, we started publishing these brief, one page, you can see right here,
it's just the front and the back,
documents on specific topics and standards
to give organizations a heads up, hence the name,
regarding what surveyors are actually citing while on survey.
And the idea was that by giving organizations a heads up,
you could then evaluate conditions in your own organizations
and identify any potential problems before survey.
And because these heads up reports are produced quarterly
and they contain actual observations and scored findings,
they're very timely and very relevant.
And you can see on this document,
that the Heads Up Report is broken out into sections.
The first section, we tried to explain the scope of the problem,
why this issue is important,
and why organization should care about the issue.
The next section lists examples of actual survey observations.
These are taken from what surveyors are actually citing on site,
and then we also try to identify what could be contributing factors
to those survey observations.
On the back side, we have what we call a "Mini Tracer,"
and it's in a checklist format,
and it actually uses the same methodology that a surveyor might follow
to find deficiencies,
as they are walking through that building tour
that was described.
And finally, on the document,
we also provide links to resources for additional information on the topic,
if you need to find more information.
Most of the resources we provided are Joint Commission related,
but we often also reference maybe the CDC,
or other important agencies, guidance, and educational materials.
And before these documents are published on our extranet site,
we vet them by subject matter experts across The Joint Commission
to ensure that the messaging is consistent,
and to make sure it's clear.
And we're at the point now that we have amassed a library
of more than 50 Heads Up Reports on all different types of topics
and they're arranged by program on your extranet site.
You can search just for NCC to see what Heads Up Reports
might be applicable for you.
We've had very good feedback about these documents,
and we hope you get a chance to utilize them.
Next slide, please.
They're available, as I said, on the The Joint Commission extranet site
in addition to a lot of other resources that have also been mentioned today.
We encourage you to take a look.
And with that, I will hand it back to our moderator, Donna.
(Donna) Thank you, Brette, and Sylvia, Beverly, Ed, Marissa, and Allison.
And thank you for all of you who submitted questions.
I just wanted to make sure our listeners are aware
that there are many great resources that we have available
in Joint Commission Connect, which is your dedicated extranet site.
I know several of our presenters talked about it:
Brette just did, Beverly did, Ed did.
The Heads Up Report is just one of them.
We want to make sure you were aware of it as a resource
and want to refer to, once you become accredited,
to learn from the ongoing survey experience,
and hope you'll optimize that and the many other resources,
you find on The Joint Commission Connect.
The tools and the resources are there for you and your team
to benefit from along the way.
It looks like we have answered all of your questions.
So with that, we're going to give you back sometime today.
We want to thank you everyone for joining us today.
We hope you found it helpful.
We wish you the best along your quality journey.
Have a great rest of the day, and be safe and well.