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Ongoing Impact of COVID-19 in Ambulatory Care Settings


By James Kendig, MS, CHSP, CHCM, CHEM, LHRM, Field Director

We’re nearly a year into the COVID-19 crisis in the U.S. and it’s time to take stock on what’s worked and what hasn’t.

Unfortunately, COVID-19 won’t be the last pandemic, even if I cringed at reading this quote from National Institutes of Health (NIH) Director Francis Collins, MD, PhD, (and boss of Dr. Anthony Fauci) in Time magazine: “We need to be prepared for whatever COVID-24 is going to look like.”

Many of us are triggered at the term “COVID-24,” but it’s a clarion call to prepare.

Research Findings on Survey Preferences
A first preparatory step is learning the needs of our accredited organizations.

The Joint Commission worked with C+R Research to conduct an assessment among several accredited health care organizations to measure the perceived impact of COVID-19. It’s interesting to see that the data validates some of the information our surveyors reported from the field.

When Joint Commission accredited organizations were asked about their survey preferences, they expressed an increased interest in virtual surveys. Research shows that 38% of respondents preferred a virtual survey during the COVID-19 pandemic; only 18% noted an in-person survey was preferred; and 44% noted a mix of virtual and in-person survey was the more preferred method of surveying. 

As The Joint Commission has offered virtual surveys since 2017, we were able to pivot to both the full virtual and hybrid (on-site and virtual) survey models.

Additional virtual surveys are being scheduled for:

  • triennial surveys
  • follow-up surveys
  • initial surveys approved to be conducted virtually earlier in the year by the Centers for Medicare and Medicaid Services (CMS)

CMS deemed initial surveys require an in-person survey once counties meet our on-site survey criteria.

Financial & Planning Shortfalls
The research also aligned with our anecdotal experience when it came to assessing how the pandemic affected monetary operations. A decrease of elective procedures coupled with the lower census numbers in many cases – which hovered at approximately 43%  – had a dramatic impact on the financial status of many health care organizations. 

Although 58% of ambulatory organizations surveyed reported their organization was less financially stable in 2020 than in 2019, this sector of health care was more optimistic than others about the rebound as 47% of accredited ambulatory organizations surveyed expected greater financial stability in 2021. 
Accredited ambulatory organizations also reported an increased need in support and resources in the areas of communications and planning. Common needs included communications on regulatory/guideline changes resulting from COVID-19, including those related to 1135 Waivers from CMS. 

Despite the need for near daily updated communications, these waivers have helped ease the burden of timely actions related to inspection, testing and maintenance activities.

Ambulatory-Specific Impact 
Some ambulatory settings have used the CMS 1135 Waivers to increase hospital capacity under the CMS program “Hospitals Without Walls.”

CMS has been allowing health care systems and hospitals to provide services in locations beyond their existing walls to help address the urgent need to expand care capacity and to develop sites dedicated to COVID-19 treatment.

Ambulatory surgery centers can contract with local health care systems to provide hospital services or they can enroll and bill as hospitals during an emergency declaration as long as they are not inconsistent with their state’s Emergency Preparedness or Pandemic Plan. The new flexibilities also leverage these types of sites to offer services typically provided by hospitals such as:

  • cancer procedures
  • trauma surgeries
  • other essential surgeries

Ambulatory settings that have been idle will need to develop a plan to address recommissioning their facility with special attention to:

  • water systems
  • power systems
  • medical equipment 
  • medical gases
  • other aspects of the physical environment that support patient care

A thorough review of these systems is necessary to assure health care organizations continue to operate as designed.

Emergency Management Updates 
We’ve worked tirelessly over the past year to try to respond to our accredited ambulatory organizations’ needs, specifically concerning support around emergency management planning, development and implementation. 

We’re currently updating standards and elements of performance (EP) in the Emergency Management (EM) chapter for all accreditation programs, including adding a much-needed glossary. Most of these EM plans were designed for a short-term disaster, such as a flood, rather than a year-long global pandemic. 
In addition, EM plans were not designed to address a long term influx of patients presenting challenges in the areas of:

  • supply
  • staffing
  • finances
  • morale

The revised standards will focus on these longer-term needs.

Survey Process Updates
We’re also evaluating the survey process to make EM sessions more meaningful for health care organizations by identifying unknown risks and sharing novel approaches to the pandemic and other environment of care (EC) scenarios.

We’ve added “lessons learned” from the Pulse nightclub shooting, Joplin tornado and other disasters into the updated standards, EPs and survey tips.

As the pandemic continues into a second year, we’ve also noticed the need to incorporate resources for staff mental health.

We’ve learned a great deal by standing by the side of our accredited ambulatory organizations over the past year. As new challenges arise, please remember, we’re only a phone call away.

James Kendig, MS, CHSP, CHCM, CHEM, LHRM, is a Field Director for Life Safety Code® surveyors/engineers at The Joint Commission. In this role, he oversees half of the surveyors who specialize in surveying The Joint Commission’s life safety, environment of care and emergency management standards. He is also the co-chair of The Joint Commissions Emergency Management Team.