Further clarification on resumption of survey and review activities
Safety for Joint Commission-accredited organizations and Joint Commission staff continues to be the priority of The Joint Commission. As The Joint Commission has resumed select on-site surveys and reviews, some further clarifications have been made regarding what is and what is not being evaluated.
Compliance with Joint Commission standards will be evaluated from the time of the last full accreditation survey up until the public health emergency (March 1, 2020). Our survey will not focus on the time period of March 1 through either the date the organization has indicated they are ready to accept a survey or the end of the public health emergency — whichever comes first.
However, The Joint Commission will assess how an organization adapted their infection control and emergency management processes in response to the pandemic and will focus its review on current practices to ensure the organization continues to provide safe care and work in a safe environment.
Also, the Centers for Medicare and Medicaid Services-issued waivers are not applicable to Clinical Laboratory Improvement Amendments-certified laboratories. Therefore, laboratories can expect surveyors to include an evaluation of the organization’s ability to appropriately manage Emergency Use Authorizations (EUAs), as well as continued management of their quality control and proficiency testing throughout the full accreditation cycle.
In mid-March, The Joint Commission stopped all on-site accreditation surveys and certification reviews in response to the National Emergency Declaration and the COVID-19 pandemic. Since on-site survey and review activities ceased, some virtual, initial surveys were conducted.
In June, The Joint Commission resumed select on-site surveys and reviews. To determine where on-site activities would resume, The Joint Commission analyzed low-risk areas — by county — to identify organizations waiting to be scheduled for surveys or reviews. Next, account executives made readiness assessment calls to the identified health care organizations to gauge the continued impact of the pandemic on the organization. Account executives assessed the following items to determine whether an organization was ready for survey or review:
- Has the organization ceased emergency operations/deactivated their Emergency Management Plan/Emergency Operations Plan?
- Is the Organization utilizing any waiver, exception or deferment that would prevent them from being compliant with any Joint Commission requirement, State or Federal regulation?
- Has the organization closed their temporary/surge capacity facilities?
- Have any staff tested positive for COVID-19 in the past 14 days?
- Does the organization have any visitor restrictions in effect?
- Does the organization have any sites located outside of their state?
When an organization was determined to be ready for on-site activities, the organization was scheduled for survey or review and surveyors or reviewers were assigned.
In preparation, The Joint Commission examined its survey and review processes and implemented the following safeguards to ensure the safety of all individuals involved in a survey or review:
- Safe physical distancing
- Limiting the number of individuals in group sessions.
- Minimizing the number of staff that accompany a surveyor or reviewer during tracer activities.
- Driving in separate or, for surveyors and reviewers, their own vehicles to off-site locations or home visits.
- Personal protective equipment
- Requiring Joint Commission surveyors and reviewers to wear masks.
- Asking that health care organizations provide masks and/or other personal protective equipment to surveyors and reviewers.
- Enhanced technology
- Maximizing technology to support physical distancing (for example, using screen sharing or projection to conduct electronic medical record reviews, interviewing care recipients or staff).
- Incorporating audio/video conference calls to safely expand the number of meeting attendees.
As health care organizations continue to battle the COVID-19 virus, The Joint Commission continues to compile resources to provide health care staff with the most pertinent information to best meet their needs. Questions related to the resumption of survey and review activities may be directed to an organization’s designated account executive.