HTMs Share Tips for Preparing for a Joint Commission Survey


Posted June 3, 2018

When faced with an impending survey by The Joint Commission (TJC), understanding the new Survey Analysis for Evaluating Risk (SAFER) Matrix methodology for scoring is pivotal, according to Therese Cortez, chief of quality management for the Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System.

Cortez was part of a team of presenters that provided advice on preparing for a TJC survey during an education session held Sunday as part of the AAMI 2018 Conference & Expo in Long Beach, CA.

In January 2017, TJC began using the SAFER Matrix to identify and communicate risk levels. With the launch of the matrix, the accreditation body eliminated category A and C elements of performance (EPs), direct and indirect EPs/findings, opportunities for improvement, and measures of success.

On its website, TJC describes the SAFER Matrix as providing "one comprehensive visual representation of survey findings in which all requirements for improvement are plotted on the SAFER Matrix according to the likelihood of the issue to cause harm to patients, staff, or visitors, in addition to how widespread the problem is, based on the surveyor’s observations."

Ilir Kullolli, director of clinical technology at Stanford Children's Health in Palo Alto, CA, said that one of the first things his hospital did to prepare for its upcoming survey was to become familiar with the most recent TJC standards, as well as the intent behind those standards.

To not get caught off guard by a TJC survey, Kullolli underscored the importance of gaining familiarity with your medical equipment management plan and related policies, keeping track of your medical equipment inventory and servicing of equipment, and performing weekly rounds.

After areas for improvement have been identified, a comprehensive improvement plan should be developed and implemented, said Kullolli. To this end, he recommended performing a mock survey, preferably with a Life Safety Inspector, in order to identify and resolve pain points in advance of the actual survey.

Kullolli said the following were among the questions asked by the TJC surveyor during his facility’s most recent survey:

  • What is the biggest risk to your hospital—both related to medical equipment and the environment of care (EOC) overall?
  • Do you have an alternative equipment maintenance (AEM) program? (Be prepared to show the data that were used when developing the program.)
  • What process do you use to ensure that home care equipment is safe for use? Also, what process is used to inspect home care equipment that enters the hospital's AEM?

Assessment of relocatable power taps (RPTs) remains an important aspect of TJC surveys, according to Kullolli, and surveyors will evaluate the decision to use RPTs, as well as the process for assigning RPTs, long-term maintenance of the RPT program, and staff adherence to the program.

Kullolli added that facilities should be ready to field questions related to:

  • Equipment moving between different hospitals.
  • EOC dashboards, such as: What improvement opportunities were identified, and how were they addressed? Reports showing progress every three to six months will be needed.
  • Hot topics in the industry.
  • Specific pain points for the organization.

Jin Matsumoto, technical career field biomedical engineer for the VA Greater Los Angeles Healthcare System, said that maintaining a well-organized computerized maintenance management system (CMMS) was a crucial part of his facility's preparation.

By standardizing its naming conventions (e.g., category, manufacturer, model) through use of the VA’s Medical Device Nomenclature System, Matsumoto said it was easier for the healthcare system to identify medical device recalls, maintenance planning, and medical equipment life cycle management.

In addition, being actively involved in EOC rounds prepared the clinical engineering department for questions asked during the TJC’s visit, Matsumoto added. Furthermore, participation in the rounds helped identify weak points to improve readiness and train clinical staff, as well as helped identify equipment that was overdue for preventive maintenance inspection.

Endeavoring to be "continuously ready for a Joint Commission survey," Matsumoto said, ultimately is the best policy.