joint commission building tour guidance

• News & Analysis

Three new Joint Commission questions for building tours

During your next Joint Commission survey, be prepared to answer three new questions before even starting your building tour. Jim Kendig, the Joint Commission’s field director for surveyor management and development, told the American Society for Healthcare Engineering (ASHE) that the questions are intended to spur conversations among surveyors and healthcare facility managers about common areas for findings.

The three new questions are:

1.    What type of fire-stopping is used in the facility? Surveyors will ask this question to find out the brand of firestopping is used and gives them a better idea of what they should expect to see during the tour. It’ll also prelude a conversation on the type of training healthcare personnel have received on firestopping and barrier management.

2.    What is the organization’s policy regarding accessing interstitial spaces and ceiling panel removal? The goal of this question is twofold. First, it helps surveyors prepare for restriction in high-risk areas. For example, surveyors could learn that ceiling tile removal is prohibited on the floor where organ transplants are done unless there is a high-efficiency particulate arrestance (HEPA) system in place. The surveyors can then arrange for the HEPA systems for that area in a timely manner. The second thing it does is help surveyors determine how sophisticated a facility’s infection prevention and facility management are. Surveyors would be on the lookout for things such as bone marrow transplants occurring in hospitals without interstitial spaces restrictions. 

3.    Which materials are used (glutaraldehyde, ortho-phthalaldehyde, peracetic acid, etc.) for high-level disinfection or sterilization? This question is focused on occupational safety and ventilation. Facility personnel should know when asked what chemicals are being used for sterilization and if the environment meets manufacturer recommendations.

“They’re pretty straightforward—there’s no hidden agenda here,” Kendig said. “We’re just trying to get some information before we start the building tour.”

More Like This

New platinum resource: cms compliance crosswalk, 2024 edition, updated cms crosswalk now available for platinum members, scheduled maintenance notification, what are hospitals required to report.

Quick Links

• Design Center
• Special Reports
• Current Issue
• Digital Edition
• White Papers

HFM Daily offers blog coverage by the award-winning HFM editorial team and links to in-depth information on health care design, construction, engineering, environmental services, operations and technology. You can read HFM Daily stories on this page or subscribe to Health Facilities Management This Week for a Friday roundup of the week's posts.

Readiness for accreditation surveys

A health care facility perspective on managing the accreditation process.

Fire pumps and the rooms where the fire pumps are housed must be inspected on a weekly basis.

Hospitals accredited by The Joint Commission (TJC) can expect an unannounced survey from TJC between 18 and 36 months after their previous accreditation survey.

However, whether or not a health care facility is accredited by TJC, this guide will provide code requirements and recommended best practices that will increase staff awareness for what to look for when conducting life safety (LS) inspections of a health care facility.

Related Article

Cms tests direct observation.

Locations the LS surveyor will want to see during the survey include the main fire alarm control panel; fire pump room; generator room; roof; operating room (OR) suite; central sterile supply; endoscopy and cath labs; isolation rooms; main piped medical gas panels; bulk oxygen and medical gas tank farm or main medical gas storage area; pharmacy; kitchen; gift shop; loading dock; hazardous areas; electrical closets; and fire and smoke barriers.

But what does that mean for the facility team, and how can the team be survey ready?

Survey ready

Immediately, the surveyor may go to the facility’s main fire alarm control panel to verify the system is functional. The facility manager will need to be able to explain to the surveyor if the fire alarm panel has any trouble conditions or disabled points and, if so, whether an interim life safety measure (ILSM) assessment is covering each item.

The facility should have a fire alarm logbook into which staff enter daily any conditions identified and have a process for making the appropriate notifications to hospital staff to conduct an ILSM assessment. Having a non-functioning fire alarm system without staff knowledge and proper ILSM assessment would be an immediate threat to life and would stop the survey.

In addition, staff must know the location of the electrical panel with the designated breaker (fused disconnect switch) for the fire alarm system. The location should be labeled at the main fire alarm panel.

Before or after surveying the main fire alarm control panel, the survey team will attend the opening conference welcoming TJC surveyors. The LS surveyor usually will not want to waste any time; they have a lot to look at in their short time in a facility. So, the LS surveyor will dismiss themselves from the opening conference after introductions, and the facility manager will meet them outside the conference room to begin the survey.

The facility orientation is when the LS surveyor will meet with the appropriate facilities staff to become oriented to the layout of the facility. This includes reviewing the facility’s life safety building feature drawings and to hear from staff if there are any areas under construction or if there are any equivalencies granted by TJC.

If a facility manager utilizes an electronic system for showing the life safety building feature drawings, it is recommended they have hard copies as a backup. Immediately following the facility orientation, the surveyor will begin the document review.

Managing documents

Document review will be conducted following TJC’s LS and environment of care (EC) documentation checklist, which should be utilized to prepare for the survey. Facility managers should make sure they are familiar with documents in the binders that the surveyor is going to ask for. The quicker the facility manager can get the document the surveyor is requesting, the better.

It may be difficult, but the facility manager should try to hand over only the exact document the surveyor is asking for. If the facility manager gives them the entire binder, they are now free to look through it all, and it may open the facility staff up to more questions. The facility manager should do several dry runs on the documentation prior to the surveyor being on-site.

A good tip is to tab the documentation binders by TJC standard. Facility managers should make sure they have everything clean and easy to read. If a facility manager has had any troubles, yellow tags or failed devices, they should make sure they have the repair ticket, work order and other documentation behind it showing they have taken action and the device is in proper working order.

Facility managers should make sure to take notes and write down anything the surveyor questions or requests. If facility managers are unable to present something to the surveyor in a timely manner, they should make sure they present it to the surveyor before they leave the facility. Even though the surveyor may still write it down as a finding, at least the facility manager has already “corrected” that finding.

The building tour

After that, the facility manager can expect the LS surveyor to start the building tour. TJC has provided a building tour guidance document available to all facilities that will aid in the preparation for a survey. Each facility should have a planned survey route that is developed during survey planning and audited during internal mock audits. While a surveyor could deviate from the planned route, it is always a recommended practice to have a planned route. The facility manager should designate a planned route and survey to that route, making sure any advanced teams know the route.

It is also recommended that each facility designate an advance team to be ahead of the surveyor doing a walkthrough of the corridors to make sure no extinguishers, medical gas shutoff valves, egress paths, electrical panels or other items are blocked by patient beds, workstations on wheels, chairs or other common items.

Facility managers should have their advance team check pressure relationships in areas such as ORs, central sterile processing departments and soiled/clean utility rooms to make sure the facility is maintaining appropriate pressure differentials. They also should check fire doors to ensure they are self-closing, latching and gaps are within the permitted limits. The team also should check for various unsecured gas cylinders as well as check the “full” and “empty” racks for the E-cylinders.

As soon as a facility is notified that TJC has arrived, the advance teams should be dispatched to their designated locations and begin tracing. 

The LS surveyor likely will first want to survey and check the air pressure relationships in the ORs and critical care rooms. This is conducted early in the survey to allow an organization time to correct any deficiencies while the survey team is on-site. During document review, the surveyor also may request to see any balancing reports for the ORs to check the air exchange rates. Facility managers should be sure to make any introductions to the OR leadership when in the OR area and have them walk with the facility team while the surveyor is in their ORs.

Facility managers will need to direct the surveyor in the proper attire, following their organization’s process on gowning to walk into sterile cores and hallways around the OR. 

While checking pressure relationships, facility managers can expect a surveyor to ask the clinical team the process if a room under positive pressure suddenly is under negative pressure. The clinical team must know if the room pressure is under constant monitoring by a central system by facilities and if a notification will be made to the facilities team or others in the organization. 

Facility managers should discuss the process with the clinical team on a regular basis and make sure everyone is able to speak about the process, including which rooms should be positive or negative and what to do in situations in which two rooms back to back are positive and which takes precedence.

If there are any deficiencies and the facility makes the corrections, a review of corrective action must include documentation that other areas supplied by the same air handler were not negatively impacted by correction work. This means a facility did not take air from another part of the building to correct an issue in the OR suite.

OR staff also will be asked about fire safety in the OR. Staff members have specific roles during a fire or smoke event. The roles of staff and licensed independent practitioners at and away from a fire’s point of origin — including when and how to sound and report fire alarms, how to contain smoke and fire, how to use a fire extinguisher, how to assist and relocate patients, and how to evacuate to areas of refuge — may be questioned by a surveyor.

The LS surveyor will want to open several ceiling tiles to check above the ceiling. Above the ceiling, the surveyor will be looking for items on the sprinkler pipes (including laying on, touching or wrapped around), penetrations not sealed or improperly sealed, and open junction boxes.

Facility managers should make sure they have material on-site to make repairs for any deficiencies cited during the survey. If the surveyor identifies a finding, the manager should take a “before” picture, get it repaired and then take another picture of the repair completed. They should also write down the location and give each finding an identification, keeping track of everything.

As with the documentation, it is best for facility managers not to volunteer information. They should be careful not to mention anything that could contribute to a “leadership” finding. For instance, they should never say, “We could fix that, but it is not in the budget.”

Findings that are not corrected immediately will require a risk assessment and, potentially, ILSMs.

Specific areas

A closer look at some of the specific areas the surveyor will be observing include the following:

Roof. The LS surveyor will be looking for proper identification of hazardous exhaust, including proper biohazard warning labels. Labeling of all equipment is recommended to avoid any questions about what equipment is located on the roof. Fresh air intakes must be located at least 10 feet from exhaust vents. Facility managers should check that there are no clogged bird screens on air intakes and no water is ponding under the intakes. Facility managers also should make sure there is no evidence of smoking.

Fire pump room. The National Fire Protection Association’s NFPA 25-2011, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems, requires fire pumps and the rooms where the fire pumps are housed to be inspected on a weekly basis. Items to be inspected each week include adequate heat in the room, proper ventilation, pump valves are open, no leaks, gauge readings are within range and pilot lights on the electrical controller are on, among others.

These are weekly inspection requirements, even though the pump itself is required to be tested on a monthly basis. The LS surveyor will be looking at the overall condition and readiness of the fire pump equipment, including pump status, whether valves are supervised and secure, and any visible leaks. The surveyor also will be checking for proper firestopping of penetrations and top-of-wall gaps, fireproofing of structural beams and for emergency lighting.

Generator room. In the generator room, one of the first things the LS surveyor will look for is the remote manual stop station (i.e., generator shut off). The remote stop should be located outside the generator room. This allows the facility manager to shut off the generators without having to further endanger anyone if there is an event occurring in the generator room, such as a fire or diesel leak.

The LS surveyor then will look at the exit sign within the generator room. These exit signs should be on a separate battery backup because they are meant to provide help if the generators fail and somebody needs to exit the room. Along with those two items, the LS surveyor will be looking at basic maintenance of the generators and the room itself.

Kitchen. Kitchens should be assessed to determine if they are considered a hazardous or non-hazardous area. If determined to be a hazardous area, the facility LS drawings should be updated and the kitchen should be inspected to the requirements for hazardous areas.

The LS surveyor will be checking that proper Class K extinguishers are installed at the proper distance from the source with the appropriate placard.

Staff knowledge will be tested by asking a staff member what they would do if there was a fire at the cooking station. Staff must be able to speak to the activation of the Ansul Inc. system and, if the system does not activate, where to find and how to properly use a Class K fire extinguisher. The range hood of the extinguishing system will be inspected for proper direction of nozzles, cleanliness and proper placement of filters. The surveyor will also look at the general condition of sprinklers in the kitchen and inside the refrigeration/freezers, if provided.

EC and emergency management

At some point during the survey, the facility manager will schedule an EC session and an emergency management session. These will consist of the EC committee and the emergency preparedness committee. The LS surveyor will look through previous meeting minutes, ask questions pertaining to current hot topics (e.g., active shooter and mass casualty) and general questions on how the committee handles different situations.

Management plans must be approved annually and kept in a binder.

The hospital must take action to eliminate or minimize risks to safety in the environment. Facility managers should be prepared to bring up a couple of examples where items on an action list have been resolved and corrected through the EC committee.

After the building tour has concluded, the final step is the exit conference, which will include a written summary of the survey findings.

Frank D. Rudilosso , PE, CHSP, is field director for facilities operations at NewYork-Presbyterian Hospital David H. Koch Center in New York City; and Jacob Allen McCall is director of engineering services at Memorial Hermann Sugar Land Hospital in Texas. They can be reached at [email protected] and [email protected] . The opinions expressed in this publication are those of the authors and do not purport to represent the opinions or views of their respective employers.

Related Articles

Cms tests direct observation for accreditation surveys.

Preparing business occupancies for accreditation surveys

Insourcing services for accreditation surveys

Search form

What You Need to Know About TJC's 2021 Survey Activity Guide

Analysis  |  By A.J. Plunkett    |    March 09, 2021

Many of the updates, such as the elimination of the Environment of Care session, are not unexpected, while other items did not change.

After some delay, The Joint Commission’s (TJC) 2021 Survey Activity Guide (SAG) is finally  online .

Be sure to check the “What’s New for 2021” section. Many of the updates, such as the elimination of the  Environment of Care session , are not unexpected. Other items did not change, such as the documents that will be requested on the first day of survey.

However, be aware that TJC is “clearly trying to get more time for tracers,” notes  Jennifer Cowel, RN, MHSA , CEO of  Patton Healthcare Consulting  and a former TJC executive and nurse surveyor.

“They eliminated the initial surveyor planning session the first morning after the opening conference.  This was normally used to review the day one documents and plan the detailed agenda,” says Cowel.

She said they have also combined two of the 30-minute sessions, Issue Resolution and Team Meeting/Surveyor Planning, into a single meeting.  That means, she says, there will be “more tracer time and less time for surveyors to plan and digest and consult with each other.”

“I would recommend that day one documents are organized, easy to access (no plastic sleeves you need to pull documents out of) and ready the very start of day one,” advises Cowel.

She suggests you also be prepared for food to be immediately available at the start of the 30-minute lunch period.  “Give them lunch and give them quiet time during this very limited lunch break. The surveyors can plan their combined 30-minute issue resolution/team meeting/surveyor planning either during the day, end of day or just after lunch. Get the team leads opinion and plans.”

Other observations from Cowel about the revisions and what it means for surveys:

• Environment of Care (EC): The EC session has been eliminated and according to the SAG “The topics that were addressed during this session will now be covered throughout the survey by Life Safety Code® surveyors and clinical surveyors during Individual Tracer, Facility Orientation, and Building Assessment activities.” Cowel notes that “related to this, the Life Safety & Environment of Care Document List and Review Tool has been expanded to add more detail on requirements.”
• New Survey Tools introduced: “They have included survey tools for Medical Staff System tracer, a kitchen tracer survey guide and a tracer tool to focus the review of the various imaging modalities and required document review,” notes Cowel. The kitchen tracer guide change was  announced  at the annual American Society for Health Care Engineering’s 2020 conference.

One tool eliminated is the Perinatal Survey Guide. Cowel notes that  new standards  are in effect this year in addition to TJC publishing a related  R3 report . “I would suggest using the standards and the guidance in the R3 reports to self-assess compliance with these new important standards.”

The SAG notes the tool has “been removed from the guide for editing and refinement for health care organizations.”

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.

Share this:

Tagged under:, most popular, researcher: paxlovid is 'game changer' in treatment of covid-19.

Recent research on Paxlovid shows there is "solid data on its effectiveness," a co-author of the study told HealthLeaders. ...

Bon Secours Mercy Health Invests in Local Supplier of PPE

A new personal protective equipment manufacturing company is set to open in Cincinnati next year. ...

Get the latest on healthcare leadership in your inbox.

• Company News

Consulting Services

• Fire Protection, Life Safety, and Accessibility Code Consulting
• Healthcare Specialty Consulting
• NFPA 241, Construction Fire Safety, Permitting and Turnover Consulting
• Laboratory / Industrial / Hazardous Chemical Compliance Consulting
• Battery & Energy Storage System Fire Safety

Inspection, Testing & Commissioning

• Fire Door Testing and Inspections
• Firestop Special Inspections
• Life Safety System Re-Commissioning & Retro-Commissioning
• NFPA 3, Fire Protection System Commissioning and NFPA 4 Integrated Fire Protection and Life Safety System Testing
• Smoke Control Special Inspections

System Design

• Fire Alarm System Design
• Performance-Based Design
• Smoke Control System Design
• Fire Protection System Design
• Third Party Reviews

Back to Insights

The Joint Commission Requires BBI (Again)

December 18, 2019

Since 1995, the Joint Commission required hospitals to maintain their Basic Building Information (BBI) and Plan for Improvement (PFI) as part of their Statement of Conditions (SOC). The BBI summarized various life safety-related features associated with the facility, while the PFI allowed hospitals to manage self-identified deficiencies which could not be immediately corrected related to NFPA 101, Life Safety Code and construction projects. The PFI was particularly a useful tool, as it prevented surveyors from citing deficiencies which were already sufficiently identified and managed by the hospital in accordance with their interim life safety measurement (ILSM) policy. In August 2016, the Joint Commission changed their survey approach and stated that all deficiencies identified would now be cited during a survey, without any special consideration given to those listed already on the PFI. The PFI list continued to remain as a tool for hospitals to manage their NFPA 101 deficiencies, however most facilities chose to no longer use this process part of the SOC, instead relying on their own internal work order or tracking system. The BBI also remained as an optional tool, however was no longer being reviewed as part of the survey process.

As of January 1, 2020, the Joint Commission has added the BBI back as a requirement and it will now have its own Element of Performance (EP). LS.01.01.01, EP 7 will require that “ the hospital maintains current basic building information (BBI) within the Statement of Conditions (SOC)” . In addition to the past information required, the BBI will also now be required to include specific square footages of the hospital’s building(s). The intent behind the accurate square footages is to assist the Joint Commission in more accurately determining the number of days required for the organization’s building tour.

It is important that hospitals dust off and update their existing BBI, especially if it has not been re-visited since 2016. This should include making sure that the construction types and occupancy classifications align with that identified on the life safety plans so all information is accurate and consistent. Accurate square footages should also be added to ensure that all facility information is complete and up-to-date. Not sure if your BBI is accurate? Please don’t hesitate to contact us if you need someone to review this information prior to your next unannounced survey.

Application of any information provided, for any use, is at the reader’s risk and without liability to Code Red Consultants. Code Red Consultants does not warrant the accuracy of any information contained in this blog as applicable codes and standards change over time. The application, enforcement and interpretation of codes and standards may vary between Authorities Having Jurisdiction and for this reason, registered design professionals should be consulted to determine the appropriate application of codes and standards to a specific scope of work.

Related Posts

PFI Process Eliminated Joint Commission

2014 Top Citations Update Joint Commission Release

An Introduction Safer Matrix

What to Expect From A Joint Commission Survey

by Micah Dickinson | Nov 10, 2021 | Fire Protection System Inspections | 0 comments

The Joint Commission is a non-profit, third-party organization that works to accredit US healthcare organizations and programs. A Joint Commission accreditation is focused on ensuring patient safety and quality of care, and the Joint Commission’s standards are aligned with the Centers for Medicare and Medicaid Services (CMS). To achieve accreditation, a hospital or healthcare organization must first undergo an accreditation survey. 

What is a Joint Commission Survey?

A Joint Commission survey is an evaluation of your healthcare facility’s performance standards. Your organization must first pass an accreditation survey to become accredited. Once accredited, Joint Commission surveyors will visit your health care organization at least once every 36 months to ensure your facility is in compliance with Joint Commission standards. These visits are typically unannounced, which can make them tough to prepare for. 

If your facility is expecting a Joint Commission survey or is working hard to stay ahead of your next Joint Commission Survey, here’s what you need to know to prepare, from what you can expect from the survey process, to what you’ll need to provide to maintain compliance. 

What Should My Facility Expect from A Joint Commission Survey?

A Joint Commission Survey is a long, rigorous evaluation process that can take anywhere from 2-5 days. As a fire protection and life safety systems provider, the Vanguard Fire & Safety team is very familiar with the building safety portion of the Joint Commission survey, and can help provide some pointers about what you should expect from that portion of the Joint Commission Survey. 

What to Expect from a Joint Commission Survey:

• A surveyor’s primary goal is to ensure that every action your staff and organization completes is in compliance with the Joint Commission’s performance standards. This includes both patient care, as well as building safety.
• On the patient care side of performance, surveyors will be evaluating each step of patient care to ensure that doctors, nurses, and other staff are in compliance, and are treating patients safely and effectively. 
• Proper system function. The building and life safety portion of the Joint Commission Survey is focused on ensuring that every component of your fire protection and life safety systems are functioning as intended. 
• Documentation. When it comes to your Joint Commission Survey, documentation is one of the most important — and time-consuming — requirements. The Joint Commission will require proof of documentation of each maintenance, inspection, and repair activity, from weekly fire alarm tests to 5-year sprinkler system inspections. 

How Can You Prepare for a Joint Commission Survey?

Given that Joint Commission surveys are most often unannounced, many healthcare organizations wonder how it’s possible to prepare. The best way to remain prepared for a Joint Commission Survey is to ensure your facility and staff are always adhering to the Joint Commission’s performance standards in every action from patient care to building maintenance. Beyond that, you can take a few additional steps to make sure your facility has everything on hand in the event of an unannounced Joint Commission Survey: 

• The Joint Commission’s Guide to Preparing for Hospital Accreditation
• Snapshot of Survey Day
• Post-Survey Process Guide
• Ensure proper documentation and organization of documentation. When it comes to your Joint Commission survey, documentation is key. The Joint Commission evaluates your compliance based on how every activity in your hospital or health organization is documented. That’s why documentation is so important, and it’s also why your facility should have a document organization strategy in place that makes it easy to pull the proper documentation, no matter when Joint Commission surveyors arrive. 

What is the Joint Commission Looking For in The Life Safety Portion of their Survey?

As a fire protection and life safety system provider, the Vanguard team is most often asked questions regarding the life safety portion of the Joint Commission’s survey. The life safety or building safety component of the survey is focused on ensuring that every element of your building is safe for both patients and staff. 

A large portion of the survey is dedicated to assessing the compliance and quality of building and fire safety practices, from preventing fires in your healthcare facility to regularly inspecting your hospital kitchen for fire hazards to practicing fire drills in your hospital , and more. Because this is such a significant portion of your survey, the Joint Commission offers a Building Tour Guidance sheet that outlines key elements that the Life Safety surveyor will assess. 

The other key component of the life safety portion of the Joint Commission’s survey is their Life Safety & Environment of Care Document List and Review Tool . 

How Vanguard Fire & Security Systems Can Help Your Hospital Prepare for a Joint Commission Survey

One of the most important components of your Joint Commission survey is documentation. The Life Safety surveyor needs to be able to verify that your fire protection and life safety systems are not only functional but have also been inspected and maintained according to their standards. 

The Vanguard Fire & Security Systems team works with hospitals and healthcare organizations to not only provide the inspections, testing, and maintenance you need but also all the information you need for proper documentation. Our digital documentation system makes it easy for your team to pull up service records in seconds, ensuring you always have the paperwork and documentation you need to present to your surveyor. 

A Joint Commission survey is a stressful time for any healthcare organization or hospital. Working with Vanguard helps remove some of that stress. Our service plans ensure your systems are inspected, tested, and serviced according to Joint Commission standards, and our easy documentation tool makes sure you always have the proof you need to confirm that service is always done in compliance with the Joint Commission’s recommendations. For more information about fire protection and life safety systems, inspection, and repair, contact the team at Vanguard Fire & Security Systems.

Recent Posts

• Fire Hose Testing
• How a Keyless Entry System Can Support Your Business’ Secure Access Control
• What Is Video Surveillance & Why Is It Important?
• Server Room Fire Hazards & Suppression Systems
• What Type of Fire Extinguisher Do I Need for a Food Truck?
• Central Station Monitoring
• Commercial Security Systems
• Fire Extinguisher Training
• Fire Extinguishers
• Fire Protection Solutions
• Fire Protection System Inspections
• Fire Safety
• Fire Sprinkler Systems
• Industrial Fire Protection
• Life Safety Systems
• Oil and Gas Fire Safety
• Uncategorized
• February 2023
• January 2023
• September 2022
• August 2022
• February 2022
• January 2022
• December 2021
• November 2021
• October 2021
• September 2021
• August 2021
• February 2021
• January 2021
• December 2020
• November 2020
• October 2020
• September 2020
• August 2020
• February 2020
• January 2020
• December 2019
• November 2019
• October 2019
• September 2019
• August 2019

TJC & CMS News Blog Information for Hospitals

Home » TJC & CMS News Blog » Hospitals

Virtual Joint Commission Surveys: Get Prepared

Feb 5, 2021 by Barrins & Associates Accreditation , Standards Compliance , Survey Readiness , The Joint Commission BH Organizations , Hospitals

Are you ready for the possibility of a virtual Joint Commission survey? As the pandemic has continued, the number of virtual surveys has steadily increased. The chart below illustrates the pattern of onsite vs. virtual surveys since May 2020.

TJC has established a Virtual Survey Framework  for how they organize virtual surveys with accredited organizations.

So, how best to prepare for this new survey process and ensure it goes smoothly? We’re sharing some tips both from TJC and from clients who’ve experienced virtual surveys.

Virtual Joint Commission Surveys: Document Review

For virtual surveys, TJC requests that you upload all required documents to their SharePoint site. So, start now to convert any paper documents to electronic formats. That way, you’ll be prepared to quickly upload them come survey time.

The required documents for Document Review are listed in the 2021 TJC Survey Activity Guide on your Joint Commission Connect extranet site. Check your accreditation program for the specific documents required for your survey.

Surveyors report that, with uploaded documents, they have much more time to thoroughly review them and plan tracers. As a result, your policies, plans, and other documents will get careful scrutiny. Much more than when surveyors had to rush through them the first morning of survey.

Also, It’s likely that, in the future, this uploading of documents will be a routine part of onsite surveys as well.

Technology Considerations

As we often encounter, it’s the technical glitches that can be the most challenging! So, a few pointers on the technology for virtual Joint Commission surveys:

First, determine the device you’ll use for the different sessions and different locations. Laptop? I-Pad? Cell phone? Make sure to carry a power cord or charger to each location in case you need to recharge.

In the same vein, test the Wi-Fi connection for each location beforehand. You don’t want to be doing a tracer on that Chemical Dependency Unit in the annex and have the Wi-Fi connection go down.

Practice using the camera for unit tours and staff interviews. For tours, many organizations use a rolling cart to transport the laptop. Surveyors will virtually inspect med rooms and observe patient care such as medication administration.

Medical Record Reviews

At this point, most organizations have electronic health records. Thus, you’ll be walking the surveyors through your EHR just as you do during an onsite survey. They’ll ask to see certain documents such as assessments, treatment plans, etc.

For this process, it’s best to identify beforehand the staff who can be the best “navigators” for the record review. Having smooth and efficient record reviews is critical. So, be sure to practice these sessions ahead of time.

If you still have paper records, talk with your TJC Account Rep about how best to review records. Options include using the camera and/or scanning. It can also be helpful to show surveyors your blank forms so they’re familiar with the contents and layout of each form.

Medical Staff and Human Resource Files

Surveyors will review Medical Staff credentialing/privileging files and HR files in the same manner as patient records. Typically, the surveyors will identify on Day 1 the files they want to review. At the same time, be prepared for additional file requests as surveyors talk with more staff throughout the survey.

Also, be aware that the TJC 2021 Hospital Survey Activity Guide contains a Medical Staff Files Review form. This is the same one the surveyors will use. Practice completing that form prior to survey so you’re up to speed.

Behavioral Health Tracers

Typical tracers for behavioral health settings in 2021 are similar to those in 2020 and include the following topics:

• Suicide risk
• Nutritional problems
• Patient treated for infection
• Transfers to ER
• Medically complex patient
• Patient on detox protocol
• Restraint/seclusion

For more info on these tracer topics, see our post Behavioral Health Tracers: Joint Commission 2020 Survey Update .

For hospital surveys, there’s also a Kitchen Tracer . Take note: The 2021 Hospital Survey Activity Guide includes the tool surveyors use for this Kitchen Tracer.

Group Meetings

There are still some group meetings on both the onsite and virtual Joint Commission survey agenda. For example: the Opening Conference, Daily Briefing, Data Use/Infection Control Session, Emergency Management Session, Leadership Interview, and Exit Conference.

For these sessions, it’s important to plan for how the various attendees will participate. Will they each call in from different locations or gather in one location? Again, make sure everyone has practiced the technology for accessing these sessions via videoconference.

Life Safety Surveyor

For virtual surveys of hospitals, the Life Safety surveyor reviews with the organization all the required Life Safety and Environment of Care documents uploaded to SharePoint. He also conducts the Life Safety Building Tour with the help of a camera and a laptop. In addition, there’s an Emergency Management session with a focus on the organization’s response to the COVID-19 pandemic.

For a glimpse into this process, see the American Society for Healthcare Engineering (ASHE) article on virtual surveys .

Survey Results: Onsite vs. Virtual

Feedback from TJC is that the survey results for virtual surveys are very similar to those for onsite surveys. The number and type of findings and SAFER matrix scoring is consistent. In addition, feedback from participating organizations has been very positive.

Barrins & Associates Consultation

We’re now conducting our Mock Surveys  and Continuous Readiness Consultations both virtually and onsite.

Client feedback has been that our virtual consultations have really helped staff feel more comfortable and prepared for their virtual Joint Commission surveys. As always, we’re prepared to support your ongoing compliance and survey readiness even in these challenging times.

To receive our free monthly eNewsletter, please provide us with your email below.

Recent TJC & CMS News Posts

• Enhancing Behavioral Health Care: Implementing Measurement-Based Care in Provider Organizations
• Joint Commission Releases New and Revised Workplace Violence Standards
• The Evolution of Texting in Healthcare: Ensuring Compliance and Patient Safety
• The Crucial Role of Safety Culture in Behavioral Healthcare Organizations 

Prior Posts

• Joint Commission Survey Preparation
• Joint Commission Continuous Readiness
• CMS Compliance Support
• Behavioral Health Organizations

The Joint Commission Launches Telehealth Accreditation

New program provides structures and processes to help healthcare organizations deliver safe, high-quality care remotely Tuesday, April 23, 2024

Media Contact:

Maureen Lyons Corporate Communications (630) 792-5171

The Joint Commission today announced it is launching a new Telehealth Accreditation Program  for eligible hospitals, ambulatory and behavioral healthcare organizations, effective July 1, 2024. This accreditation program provides updated, streamlined standards to provide organizations offering telehealth services with the structures and processes necessary to help deliver safe, high-quality care using a telehealth platform.

The Telehealth Accreditation Program was developed for healthcare organizations that exclusively provide care, treatment and services via telehealth. Hospitals and other healthcare organizations that have written agreements in place to provide care, treatment and services via telehealth to another organization’s patients have the option to apply for the new accreditation.

The Telehealth Accreditation Program’s requirements contain many of the standards similar to other Joint Commission accreditation programs, such as requirements for information management, leadership, medication management, patient identification, documentation, and credentialing and privileging. Requirements specific to the new accreditation program include:

• Streamlined emergency management requirements to address providing care and clinical support remotely rather than in a physical building.
• New standards for telehealth provider education and patient education about the use of telehealth platforms and devices.
• New standards chapter focused on telehealth equipment, devices and connectivity.

Additionally, the program’s standards may be filtered based on the telehealth modality or service provided.

“The use of telehealth in the United States increased 154% during early stages of the COVID-19 pandemic and stabilized at levels 38 times higher than levels in 2019. As telehealth continues to evolve, it was imperative to create a new accreditation program to provide a framework to support the integrity of patient safety regardless of the care setting,” says Jonathan B. Perlin, MD, PhD, president and chief executive officer, The Joint Commission enterprise. “Our new Telehealth Accreditation Program helps organizations standardize care and reduce risk so that all patients, including those obtaining services remotely, receive the safest, highest-quality care with outcomes consistent with traditional settings.”

The Telehealth Accreditation Program will replace the current telehealth and technology-based accreditation products in The Joint Commission’s Ambulatory Health Care and Behavioral Health Care and Human Services Accreditation Programs for organizations that meet the eligibility criteria.

To learn more about the Telehealth Accreditation Program, please visit  The Joint Commission website .

About The Joint Commission

Founded in 1951, The Joint Commission  seeks to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare. Learn more about The Joint Commission at www.jointcommission.org .

• Dateline TJC
• Advancing Health Care Equity
• Ambulatory Buzz
• At Home with The Joint Commission
• Improvement Insights
• Leading Hospital Improvement
• Quality in Senior Living
• Joint Commission Saves Lives
• Media and Blog Highlights
• Fact Sheets
• Supporting Research
• Collaboration
• Newsletters
• News Releases
• Speakers Bureau
• Video Resources
• The Joint Commission and Social Media