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Some Regular Surveys and Review Activities Resuming With Extra Safety Considerations in June

The Joint Commission will begin resuming some surveys and review activity in June. 

The Joint Commission is committed to working closely with organizations, with safety being the first and foremost priority. As we start to resume some of these surveys and review activities, account executives will begin to contact organizations due for a survey to assess the impact that the coronavirus pandemic had on their operations and their current state.

The Joint Commission is reviewing a variety of factors and criteria for determining where and which organizations will be surveyed, including identifying and then prioritizing low-risk areas in which we can go in safely to survey. 

Our survey process will look somewhat different, as we will need to employ physical distancing practices to ensure the safety of all parties. These will include:

  • Limiting the numbers of individuals in group sessions. The use of audio or video conference calls can be incorporated by the organization to safely expand the number of attendees. 
  • Minimizing the number of people who accompany the surveyor on tracer activities.
  • Using masks will be a routine practice, and we will expect the organization to provide masks and/or other personal protective equipment (PPE) to surveyors and reviewers while on-site. 
  • Maximizing the use of technology to eliminate the need for a number of people to sit directly next to an individual for an extended time. For example, conducting electronic medical record reviews using screen-sharing or displaying/projecting the record. Other examples include simulating an activity if we are unable to enter a high-risk space, and interviewing patients or staff by phone.
  • Driving in separate cars to off-site locations or home visits. 

Our survey will focus on a thorough assessment but will not retroactively review compliance. The implementation of an organization’s emergency operations plan will not be the focus of return survey activity considering the Centers for Medicare and Medicaid Services (CMS) waivers and other extensions. Rather, we will work to understand how you have adapted to the pandemic and review your current practices to assure you are providing safe care and working in a safe environment.

The Joint Commission has been compiling resources to provide health care staff with the most pertinent information to best meet their needs as they battle the COVID-19 virus. The resources are available on The Joint Commission’s website.

Questions regarding the resumption of these surveys and review activities may be directed to your organization’s assigned account executive.

Mark G. Pelletier, RN, MS is the chief operating officer, Accreditation and Certification Operations, and chief nursing executive for The Joint Commission. Prior to his current position, Pelletier served as the executive director for the Hospital Accreditation Program and was also responsible for business development in the Hospital, Critical Access Hospital and Laboratory accreditation programs. Mr. Pelletier has more than 30 years of experience in hospital operations, performance and quality improvement, process redesign, and program development. Previously, he was the senior vice president and chief operating officer of Condell Medical Center, Libertyville, Illinois. He has also served in executive positions for several hospitals in the Chicago area including Resurrection Health Care, Northwestern Memorial Hospital, Children’s Memorial Medical Center and Mercy Hospital Medical Center. Mr. Pelletier earned a Bachelor of Science in nursing and a Master of Science in administration from DePaul University, Chicago.