The Joint Commission’s Offsite Surveys for Healthcare

It’s evident that COVID-19 was unexpected and the anticipated impact at its onset in Spring, 2020 was grossly underestimated. Of course, this prompted many industries and companies to adapt and pivot their strategies and operations in hopes to survive and provide continued value to their customers and partners. 

With some onsite work transitioning to remote, it seems that there may be appetite and acceptability for more virtual and offsite work. This is no different for The Joint Commission (TJC), a non-profit organization that serves to accredit more than 22,000 US healthcare organizations and programs along with many more medical services around the world with their international branch.

From their website, TJC’s mission is “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.” In the pre-COVID era, TJC surveyors would be responsible for carrying out this mission on the front lines of healthcare by conducting unannounced surveys once every three years — in-person, onsite. With COVID and the consequent limited visitor access at hospitals, TJC adapted by beginning offsite surveys to also protect their surveyors.

Joint Commission Survey

In OR Manager’s editor’s note last month, corroborated by TJC, we have access to some interesting information as to how TJC adapted to offsite surveys and the success of this new program thus far.

  • All onsite surveys were stopped for 2.5 months starting mid-March due to COVID-19. In this time, TJC began preparing processes and establishing procedures for offsite surveys.
  • From June 2020 to the end-of-year (Dec 31, 2020), TJC conducted more than 1200 offsite surveys and reviews.
  • Not all programs and organizations are eligible for an offsite, virtual survey or event. This depends on a number of factors including state-level restrictions on virtual processes.
  • If your organization is eligible and meets the criteria for an offsite survey, TJC would have sent out a questionnaire survey using Qualtrics to gauge interest in participating in offsite surveys.
  • More than 3000 questionnaires have been sent out and TJC says the response has been tremendous.
  • Following the questionnaire and eligibility determination, you’ll receive communication from TJC to schedule a technology test before proceeding. After all, it’s important to make sure your technology systems will be stable and can handle the offsite survey without interruption or technical difficulties.

There are always benefits and drawbacks to structural and procedural changes such as this transition to offsite surveys. TJC took the right approach and continues to do so by establishing criteria for eligibility. This, in addition to gauging organizational interest, allows for flexibility in this new process while maintaining expectations and compliance. Organizationally, the virtual option allows for healthcare to keep patients first (especially if COVID numbers are high in their area) without a degradation of acceptable quality and patient safety.

There’s a good reason why TJC surveys are normally unannounced; quality and patient safety should always be maintained and improved regardless of a looming survey. With the offsite option, organizations can be held to the same level of accountability in a time where it matters most, albeit with seemingly less stress than an onsite survey, which staff appreciates. 

During these COVID times and with onsite and offsite surveys, it can be effective for an organization to take an incremental strategy to improve quality and patient safety without getting overwhelmed with solving all problems at the same time. Easy and straightforward implementations, such as GloShield for managing surgical fire risks (TJC EC.02.03.01), will establish quick wins and help motivate cultural and organizational momentum to strive for additional initiatives that enhance safety and quality. Continuous improvement and monitoring on an organization’s end will help it be prepared for an unannounced survey.

Perhaps what is most interesting with this new virtual process is forecasting the longevity of this adaptation. Will TJC revert completely back to onsite surveys at the “end of COVID,” or will TJC take a continued hybrid approach to aid with the effectiveness of achieving their mission? We’re seeing other industries and organizations make the switch to virtual (some more easily than others) but as with all things, only time will tell. What we do know is that as the US continues to battle COVID-19 into the first and second quarter of 2021, TJC will “continue to monitor offsite eligibility criteria and will extend offsite opportunities to more organizations as criteria allows.”

If you or your organization has any questions about the offsite survey and review process, we invite you to direct these inquiries to your organization’s designated TJC account executive. If you’d like to learn more about GloShield and its surgical fire safety benefits, visit the Jackson Medical website for information or to contact us.

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