San Antonio
APIC
MARCH 2011
THE JOINT COMMISSION SURVEY
PROCESS OVERVIEW
AGENDA
 TJC Survey Process (hospitals)
 TJC Chapter Requirements
 Periodic Performance Review (PPR)
 Survey Readiness
 Infection Control & Prevention Chapter
 Resources
 Discussion & Questions
OBJECTIVES
 Provide an overview of TJC Survey
Process (hospitals)
 Review the TJC Chapter Requirements
& Infection Control & Prevention
Chapter
 Discuss Periodic Performance Review
(PPR) & Survey Readiness
 Share TJC Survey Related Resources
TJC SURVEY PROCESS
 Unannounced Survey Process
Posted on TJC secure extranet site by 7:30 a.m.
 Survey window – 18 to 39 months after previous full survey
 Strategic Surveillance System (S3- past survey findings,
ORYX® core measure data, data from the Office of Quality
Monitoring (complaints and non-self reported sentinel
events), data from an organization’s electronic application,
and HCAHPS data.
 TJC Survey Team Composition (based on size &
complexity of your organization) -> Lead Surveyor,
Administrator, Nurse, Generalist, Specialist (e.g. lab), Life
Safety Code Specialist

TJC SURVEY PROCESS
 Opening Session (Leadership)– survey overview & orientation





to organization
Document Review – Policies, Plans, Meeting Minutes, Census
Individual Tracer Activity– Isolation Patient, Surgical
Patient
System Tracers – depends on the size/complexity of your
organization
 Infection Control & Prevention
 Medication Management
 Data Use
Program Specific Tracers – suicide prevention, patient flow,
lab integration
Competency & Medical Staff Credentialing & Privileging
TJC SURVEY PROCESS
 Infection Control & Prevention System
Tracer



Composition of Team (IC members -> Employee Health,
Pharmacy, Lab, EVS, Facilities Management, Nursing,
Procedure Areas)
Scheduled after Document Review & Individual Tracers
Discussion - review of accomplishments and opportunities
 Exit Briefing & Exit Summary - “Summary of
Survey Findings Report”



Direct Impact Standards
Condition of Participation Deficiencies -> Central Office
Review
Indirect Impact Standards
Infection Control & Prevention System Tracer
 IP Program Assessment & Plan
 Population Demographics  Annual Plan
 MDROs -> Lab (culture result tracking), Pharmacy, Dietary,
EVS, NPSG, tracking
 SSIs -> Health Optimization Prior to Elective Surgery, types of
procedures monitored, Joint, Cardiac and Bariatric Surgery
 Device Related Infections -> CLABSI, VAP, CAUTI
 Review of a patient in isolation as a table top tracer
 Type of isolation
 Education of staff, patient, visitors
 Tracking & Notification
TJC SURVEY PROCESS
 Potential Accreditation Decision – “Accreditation Survey
Findings Report” posted on secure extranet site includes the
potential accreditation decision (within 2 days usually)
 Central Office Review – COP, Immediate Threat, Situational
Decision Rules
 Final Accreditation Decision – Evidence Standards
Compliance (ESC)
 Immediate Threat to Health or Safety
 Situational Decision Rules
 Direct Impact Standards (45 days)
 Indirect Impact Standards (65 days)
 MOS – 4 months
Continuum of survey activity outcomes
• Preliminary Accreditation (Applicable to the Early Survey
PA/ •
A
Policy - 1st time accreditation of new organization)
Accredited (Compliance with all standards or successfully
addresses RFIs in an ESC within 45 or 60 days)
• Accreditation with Follow-up Survey (not in
AFS
Cont
compliance with specific standards that require a follow-up survey in 30
days to 6 months – ESC still applicable)
• Contingent Accreditation (fails Accreditation with Follow-up
Survey or does not have a required license, follow-up survey in 30 days)
• Preliminary Denial of Accreditation (Immediate Threat to
PDA
DA
Health or Safety, Failure to resolve requirements of AFUS after two
opportunities or CA; or Significant Standard Non-compliance)
• Denial of Accreditation
Reports that meet a decision rule that automatically triggers a PDA, Cont or AFS or
a report with a CMS Condition level or APR deficiency will be reviewed by TJC
Central Office. Reminder: CMS conducting validation surveys
TJC CHAPTER REQUIREMENTS
 Chapter – NPSG, EC, EM, HR, IC, LD, MS,PI,TS
 Standard (Requirement) – statements that define the




performance expectations and/or structures or
processes
Rational – background, justification, additional
information
Element of Performance (EP) – identify
performance expectations
References – help to identify related standards/EPs
Icons
TJC CHAPTER REQUIREMENTS
 Numbering Requirements
 Standard six digit number broken down into three sets of two
numbers each
 For Example, IC.02.04.01
First two letters are the chapter acronym
 First two digits refer to the Roman numeral in the outline
 Second two digits refer to the letter under the Roman numeral in
the outline
 Last two digits refer to the standard number

Chapter
Roman Numeral Letter in Outline Standard
Number
IC
02
04
01
Infection
Prevention and
Control
II (section –
Implementation)
D
01
TJC CHAPTER OUTLINE - IC
 I. Planning
A. Responsibility (IC.01.01.01)
 B. Resources (IC. 01.02.01)
 C. Risks (IC.01.03.01)
 D. Goals (IC. 01.04.01)
 E. Activities (IC. 01.05.01)
 F. Influx (IC. 01.06.01)
 II. Implementation
 A. Activities (IC.02.01.01)
 B. Medical Equipment, Devices, and Supplies (IC.02.02.01)
 C. Transmission of Infection (IC. 02.04.01)
 III. Evaluation and Implementation (IC. 03.01.01)

TJC Glossary of Terms
What is the time line
for resolution of noncompliant findings?
What is the immediacy
of risk to the patient?
High
Immediate
Threat
Short
Situational
Decisional
Rules /
Contingent
Accreditation
Direct Impact
E
P
Element of Performance
M
Measure of Success required
D
Written Documentation required
2/3
EP Criticality Tag: 2=Situational
Decisional Rule; 3=Direct Impact
A/C
Scoring Category: A=Y/N; C=3
strikes out
EP Scoring Scale
Low
Indirect Impact
Long
0
Insufficient Compliance
1
Partial Compliance
2
Satisfactory Compliance
Example – Scoring and Icons
Scoring
Category
Documentation
Scoring Scale
Criticality Tag
3
MOS
TJC Periodic Performance Review
 Tool for self-assessing compliance with standards
and requirements between on-site surveys
 Process to identify potential areas of concern, and
opportunities to make ongoing adjustments.
PERIODIC PERFORMANCE REVIEW
 Organization’s self assessment with chapters,
standards and EPs
 Noncompliant Standard – Plan of Action(POA);
Measure of Success (MOS)
 Completed annually one year after survey
 Several Options for submission
 Full PPR and 3 other options
PERIODIC PERFORMANCE REVIEW
Review
using
resources
PPR ASSESSMENT
BY CHAPTER
CHAMPION
OFI
Action Plans
MOS
CHAPTER
CHAMPION
completes Scoring
Questions:
Contact Facility
Administrator
Submission to TJC
Facility Administrator
concurs/revises scoring
TJC Survey Readiness
 PPR – self assessment & POAs/MOS
 Mock Individual/Patient, Progam Tracers – IP and
Team
 Infection Prevention & Control related examples


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
Isolation Patient Tracers – MDRO’s, Precautions
Surgical Patient
Instrument handling and reprocessing
Biohazard Waste
Food and Nutrition Services
Environment of Care
 Practice Infection Control System Tracer
TJC Survey Readiness
Regional
Mock
Tracers
Follow-up
Regional
Mock
Tracers
Facility
TJC
Readiness
Facility &
System
OFI
Scorecard
&
Executive
Summary
Infection Control & Prevention
Chapter Summary - Planning
 IC.01.01.01 – Identifies individual(s) responsible for





program
IC.01.02.01 – Leaders allocate needed resources for
program
IC.01.03.01 – Hospital identifies risks for acquiring
and transmitting infections
IC. 01.04.01 – Based upon risks hospital sets goals to
minimize possibility of transmitting infection
IC. 01.05.01 – Hospital has an IP and Control Plan
IC. 01.06.01 – Hospital prepares to respond to an
influx of potentially infectious patients
Infection Control & Prevention
Chapter Summary - Implementation
 IC.02.01.01 – Hospital implements its IP
and Control program
 IC.02.02.01 – Hospital reduces the risk of
infections associated with medical
equipment, devices, and supplies
 IC.02.03.01 – Hospital works to prevent
transmission among patients, LIPs and staff
 IC. 02.04.01 – Hospital offers vaccination
against influenza to LIPs and staff
Infection Control & Prevention
Chapter Summary – Evaluation & Improvement
 IC.03.01.01 – Hospital evaluates the
effectiveness of its IP and Control Plan
National Patient Safety Goals
 Goal 7 – Reduce the risk of health-care
associated infections
 Meeting
Hand Hygiene Guidelines
 Preventing MDRO’s
 Preventing CLABSI
 Preventing SSI
2012 – VAPs and CAUTI
 Sentinel Events – separate chapter
2010 Challenging Standards - IC
 Identify risks for acquiring/transmitting infection.
IC.01.02.01/EP#1&2 (Identify & prioritize risks
based on location, community, and services
provided)
 Reduce the risk of infections associated with medical
equipment, devices, supplies. • IC.02.02.01/EPs
#1,#2, #4 (Implement infection prevention and
control activities when cleaning, performing
disinfection, sterilizing, and storing) {DIRECT
IMPACT}
Resources Available
 JCR & TJC Publications – Perspectives
 Infection Prevention & Control Publications
 TJC Hospital E-dition 2011 (updated July and before January)
 TJC website (www.jointcommission.org/Standards/FAQs)



BoosterPak
R3 Report
TJC Leading Practice Library
 Joint Commission Center for Transforming Healthcare
(www.centerfortransforminghealthcare.org/)
 IP Networking
TJC BoosterPak
(As of January 2011 two BoosterPaks Published)
Full
version
available
on HITT
site.
R3 Report
(As of January 2011 One Report Published)
Leading Practice Library
Leading Practice Library