Joint Commission utilizing hybrid survey approach for document review
The Joint Commission has begun utilizing a hybrid survey approach with a document review surveyor (DRS). This approach has been approved by the Centers for Medicare and Medicaid during the public health emergency. The Joint Commission is currently utilizing the hybrid approach during deemed hospital reaccreditation surveys meeting eligibility criteria — primary of which is a fully electronic health record.
The hybrid approach consists of a Joint Commission surveyor working remotely to review patient records, documents, and human resources and credentialing files while the remaining members of the organization’s survey team are onsite. The survey team will need use of either Zoom or Microsoft Teams for the hybrid approach.
The remote surveyor’s primary responsibility will be to review closed patient records through the shared screen function, such as:
- Transfers (higher and lower levels of care)
- Death records, including autopsies and organ donation
- Patients with grievances with grievance policy application
- Patients with care provided by a contracted service so evaluation of contracted services can be performed
- Patients with critical tests
- Patients with blood transfusions
Documents also may need to be reviewed by the remote surveyor. Those documents will be uploaded into a secure SharePoint site and deleted after the survey. The remote surveyor will ask for names of individuals who will need access to SharePoint to upload the requested documents. Examples of documents that may be requested are:
- Medical Staff bylaws and rules and regulations
- Pharmacy Sterile Compounding Room Reports
- Pharmacy Hood Certifications (may include Pharmacy staff competencies)
- Infection Control Plan and Evaluation
- Organ Donation Policies
- Autopsy Policy
- Agreement with outside blood supplier
- Agreement with organ/tissue procurement organizations
Organizations should plan to have a scribe and another staff member present who can easily navigate the electronic health record and has access to all record components. Questions on the hybrid approach can be directed to the organization’s designated account executive.