Documents Request for the Survey Planning Session - Hospital and Critical Access
TJC Mock Survey
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Documents Needed Prior to the Arrival of the Survey Team
List of all sites that are eligible for survey
List of sites where deep or moderate sedation is in use
List of departments/units/areas/programs/services within the organization
List of sites where high-level disenfection and sterilization in use
Organizational chart
Most recent Focused Standards Assessment (FSA)
Documents Needed Upon Arrival of the Survey Team
Instructions: Organize your documents by placing them in a notebook or in folders a file box. Make sure each
document is clearly labeled.
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Name/Phone number of key contact person who can assist surveyors in planning tracer
selection
Lists of scheduled surgeries and special procedures, e.g. cardiac catheterization,
endoscopy lab, electroconvulsive therapy, caesarian sections, including location of
procedure and time. This is needed every morning of the survey.
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List of patients that includes: name, location, age, diagnosis and length of stay, admit
date, source of admission (ED, direct admit, transfer) This is needed every morning of
the survey. Please make enough copies for each nurse or physician surveyor.
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Hospital license
CLIA certificates
Map of the organization
Most recent TJC survey accreditation report
Any CMS or State survey/complaint/related reports for the 12 months prior to the mock
survey
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Documents Needed During the Course of the Survey
List of unsafe abbreviations
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List of all contracted services
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Agreement with outside blood supplier (n/a for critical access hospitals unless they
operate rehab and distinct part units)
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Agreement with organ procurement organization
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Agreement tissue and eye procurement organization
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Organ, tissue, and eye procurement P&P
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Organ donation and procurement conversion rate (Hospital)
Performance Monitoring and Improvement Documentation
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Performance improvement (PI) data from the past 12 months
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Documentation of PI projects being conducted, including the reasons for conducting the
projects and the measurable progress achieved (this can be documented in governing
body minutes or other minutes)
Medication error reports and adverse drug reactions
Patient event, incident, unusual occurrence reports
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Analysis from a high-risk process
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Documents Request for the Survey Planning Session - Hospital and Critical Access
TJC Mock Survey
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ORYX data – only for very small hospitals exempt from submitting this data through
vendors
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Infection Control (IC)Plan
IC annual risk assessment & annual review of the program
IC assessment-based, prioritized goals
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IC surveillance data from the past 12 months
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Patient flow documentation: dashboards and other reports reviewed by hospital
leadership; document of any patient flow projects being conducted (including reasons for
conducting the projects); internal throughput data collected by emergency department,
inpatient units, diagnostic services, and support services such as patient transport and
housekeeping
QAPI committee minutes for the past 12 months
IC committee minutes for the past 12 months
Medical Staff Documentation
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Medical staff bylaws and rules and regulations
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Medical Executive Committee meeting minutes
Environment of Care, Emergency Management, and Life Safety Documentation
Behavioral Services Physical Environment Risk Assessment
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Environment of Care data including the Statement of Conditions (SOC) from the last
survey
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EC management plans and annual evaluations
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EC multidisciplinary team meeting minutes for the past 12 months
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Emergency Operation Plan (EOP) and annual evaluation
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Hazard Vulnerability Analysis
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Emergency management drill records and after action reports
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Written fire response plan
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Interim Life Safety Measure P&P
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Fire drill evaluations
Life Safety drawings
Inspections for the fire alarm system, smoke detectors, fire extinguishers, fire sprinkler
system, fire hydrants, and kitchen hoods
Fire drills for last 16-18 months
Inspections for any special agent extinguishers for last 24 months
Generator testing logs
Infection control during construction P&P
Operating room temperature & humidity records for the past six months
Environmental testing reports for assessment of air changes and positive/negative
pressures
A written inventory of (all medical equipment) or a written inventory of (selected
equipment categorized by physical risk associated with use including all life-support
equipment and equipment incident history). The inventory should be current to show any
new types of equipment having been evaluated prior to use.
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Documents Request for the Survey Planning Session - Hospital and Critical Access
TJC Mock Survey
The hospital policy(s) defining frequencies for inspecting, testing and maintaining medical
equipment on the inventory based on criteria such as manufacturer’s recommendations,
risk levels or current hospital experience.
A written inventory of all operating components of utility systems or of selected
operating components of utility systems based on risks for infection, occupant needs and
systems critical to patient care, including all life-support systems. The inventory should
be current to show any new types of equipment having been evaluated prior to use.
The hospital policy(s) identifying the intervals for inspecting, testing and maintaining all
operating components of the utility systems on the inventory, based on criteria such as
manufacturer’s recommendations, risk levels or current hospital experience.
Infant abduction plan and code exercises
Written plans for actions taken in the event of utility disruptions
Inspections conducted by State, local, federal or other authorities for the past two years
Other Documentation
Executed QIO agreement; in the absence of an agreement with a QIO, the organization’s
Utilization Review Plan (n/a for Critical Access Hospitals unless they operate Rehab and
Distinct Part Units)
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Governing Body minutes for the past 12 months
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Medical record delinquency data
Policies and Procedures (P&P)
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Autopsy
Blood transfusion
Complaint/Grievance
Restraint and seclusion
Waived testing P&P and quality control plan
Notes:
1. This list contains items that TJC requests for the accreditation survey as well as items
that Compass requests for the mock survey. For the actual TJC survey, only provide the
items specifically listed in the current TJC Survey Activity Guide.
2. Surveyors may need to see additional documents throughout the survey to further
explore or validate observations or discussions with staff. Please provide a folder with the
surveyor’s name on it and place additionally requested documents in it. Please provide a
box/recycle bin for us to return documents to you when we are finished.
3. Selected personnel files for employees and contractors observed during the survey
will also be requested for review.
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