By Amy Null, MBA, MT (ASCP), SBB, Associate Director, Standards Interpretation Group, and Surveyor
If your organization is accredited by The Joint Commission, the day will come when our surveyors show up at 8:00 a.m.
If you’re prepared for it, the experience should be a positive one.
No organization undergoing initial accreditation should be caught entirely off guard by a surveyor(s) arrival. The organization has a three-month window for the survey period and an email and JC Connect notification are sent on the day of the survey around 7:30 a.m. local time.
Preparation Before the Opening Conference
Our surveyors greatly appreciate when a member of the team comes out to greet them upon arrival at the start of survey. It also is helpful when the organization has an internet connection ready and available for the surveyor to use throughout the survey. If the surveyor needs to wait for someone from IT to come and assist with an internet connection, it can delay the start of the opening conference.
Here are a few tips to start the day on a good note.
- Fill out The Joint Commission electronic application, e-app, completely. The selected number of specialties and subspecialities, locations, and number and type of CLIA certificates drive the number of survey days at your organization.
- Review resources from The Joint Commission website. Our FAQs are updated frequently and answer many pre-survey questions. The Comprehensive Accreditation Manual for Laboratory and Point of Care Testing (CAMLAB) is where all the laboratory standards reside. You must be familiar with this manual as we survey to these standards and elements of performance (EPs). To determine which standards and EPs pertain to each specialty/subspecialty, consult the Standards Applicability Grid (SAG) chapter in the manual.
- Create a Survey Manual. This “book of evidence” which contains many of the resources/documents that the surveyor will ask to review during the survey. A great place to start is to review the “Laboratory Accreditation Document List” which is in the Laboratory Accreditation Survey Activity Guide. This list provides a high-level overview of many of the documents that will be reviewed during the survey.
- Reach out to account executive. Please consider your account executive as a go-to resource who can answer many of your pre-survey questions. If the account executive cannot answer your questions, they may escalate them to another department within The Joint Commission or may recommend you submit your question online to the Standards Interpretation Group (SIG). You can request a return email response, or, a return phone call for more complex questions.
- Assemble team for opening conference, lab tour and medical record review.
Opening Conference
The opening conference starts quickly after the team is assembled. Anyone from the team who can participate is encouraged to do so, including:
- lab directors
- department leaders
- staff
- infection control personnel
- members of the C-suite
- human resources
At some point during the first day, your surveyor(s) will ask for a lab tour. Designate a staff member to help navigate the patient medical record as the surveyor will review patient laboratory results as they are viewed by the health care providers who are caring for the patient.
Proficiency Testing
Documentation on proficiency testing is considered an indicator for how the rest of the survey will go. As a general rule of thumb, if an organization’s proficiency testing documentation is easy to locate and shows that consistent processes are in place, the rest of the documentation tends to follow suit. By the same logic, if the organization can’t find its proficiency testing data or every event is organized in a different order or is not consistent, it can be a precursor for how additional documentation is maintained in the laboratory.
Proficiency testing is a complex area – it is rare for an organization NOT to have a finding in proficiency testing. If possible, assign one individual in the laboratory to be responsible for the proficiency testing process.