Human Resources Department
The Joint Commission
Survey Results
August 2013
HR Chapter
The Joint Commission Survey Results

Competency Interview and File Review both occurred on Day 4 of survey.

Last minute change in schedule moved file review to morning time.

Many thanks for all those who jumped in to get the files and accompanying
documents over to the medical center quickly when interview time changed.

Focus for files was on performance evaluations for last three years; licenses and
credentials, back-up documentation to support competencies and education and
health information.
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Surveyors were very detailed in what they were looking for.
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Three surveyors reviewed files at the same time with 3 HR staff and appropriate
managers.
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Did not have all back-ups docs available when file was called for review. Provided
back-up docs later in day.

Decentralized system proved to be challenging to maintain all required documents.
HR Chapter
The Joint Commission Survey Results
19 Files were requested from the following departments /units:
 Inpatient Nursing: Float Pool; L&D; 6 East; 4 ICU; 7 North; 7 ICU
 Other Areas: Spiritual Care; ED; Bone Marrow Transplant; Speech Pathology;
Orthotics and Prosthetics; Pharmacy; Radiation Oncology; Rehab-NRRU
Job Titles that were requested:
 Inpatient Nursing: PD RN; Traveler RN; CN I, CN II; AN II; Unit Manager
 Other Areas: Pediatric Chaplain; Clin Lab Manager; Dept. Manager; Emerg Trauma
Tech; AN I; MSO II; MSO III; CN III; CN II; Rad Ther Tech; OT IV; Staff Pharmacist
HR Chapter
The Joint Commission Survey Results
OBSERVATIONS & FINDINGS

Centralized system for Nursing files resulted in positive feedback from surveyors.

All required docs found in Nursing files (3 yrs of licenses, competencies and evals).

Compliments from Surveyors on Nursing Filing System and process.

Competency and Education binders made available to support forms in file.

Asked for three years of performance evaluations in every file.

Back-ups docs were not all readily available to support summary sheets in file.

Need to get completed paperwork to HR from departments in more timely fashion for
filing. Will be implementing guidelines with timeframes.

Important for departments to stay on top of health information to insure entry.

Primary Source Verification remains priority!
* Two weeks after survey, the HR finding for performance evaluations was overturned when HR provided
evidence of overall organizational compliance. TJC changed score from noncompliant to compliant.
HR Chapter
The Joint Commission Survey Results
Observations and Findings: Steps Going Forward
Back-Ups Docs
 It’s very important that every competency summary sheet has material readily
available to support task.
 Departments must have process/binder/system to share information used to
support competency during file review sessions.
Primary Source Verification
 We will be sending out a request for every area to identify the job titles in
their department that have credentials required and share the renewal
timeframes.
 Must create updated spreadsheet with every credentialed title for the
organization.
*Setting up new contract with outside company that will verify all licenses for health system upon hire and
renewal.
HR Chapter
The Joint Commission Survey Results
Observations and Findings: Steps Going Forward
Filing process

Due to centralized and non-centralized combination process currently set up
for personnel files in medical center for non- inpatient nursing files, we must
have guidelines for submitting paperwork in timely and reliable fashion.

If we can’t accomplish this, we will move to centralizing all files throughout
organization in HR.
Personnel Files

Converting to Nursing file format.
HR Chapter
The Joint Commission Survey Results
Competency Interview
Topics Discussed:

Recruiting, Interviewing and Hiring Process

Nursing Turnover

Competency Process

Orientation Programs

Education Opportunities



Thirty managers, supervisors and educators participated.
Shared department processes. Collaborative effort.
Competency binders and materials were shared. Impressive interview.
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Upcoming VAD Survey

VAD Survey is August 12th and 13th.

There will be a file review and competency interview.

Those areas who work with any VAD patients, please verify documents are up
to date in file and any paperwork that needs to get to HR is delivered by
Monday, Aug. 12th.

Must have all license verifications, evaluations, competencies and education
docs in personnel file.

Managers/Educators must bring supporting docs to interview to back-up
summary sheets in file.
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Additional Information
CPR Cards

Handwritten cards are now allowed again as long as they are legible.

AHA removed the requirement for computer generated or typed cards
only.
Flu Survey

A 2013-2014 flu survey will be announced by OHF in Sept/Oct. HR
Tracking Field has 8/31/13 expiration date for organization.
i.
ii.
iii.
No survey available now.
Wait for email announcement.
Then have your staff complete survey.
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