Competencies, Training, and Fire Safety: All Fair Game During Joint Commission Surveys
Employees in clinical areas are aware that surveyors from The Joint Commission (TJC) could arrive at the hospital at any time unannounced. The same is not always true for registration areas.
“There is a potential for patient access to be somewhat out of the loop, as much of the survey is focused on clinical care,” says Kelley Joyce, director of patient access services at Brigham and Women’s Hospital in Boston.
Registration and admission staff are the first employees patients meet. That means these employees also are the first ones surveyors will approach, as surveyors begin patient tracers on the admission process.
“[Surveyors] will want to be walked through your workflow from beginning to end, with a focus on patient privacy and patient rights,” Joyce notes.
The role of patient access has expanded considerably, along with the list of possible questions TJC surveyors could ask. “Surveyors could ask any question related to job responsibilities,” warns Sheila Peck, a regulatory and accreditation consultant for Moffitt Cancer Center in Tampa, FL.
During previous TJC visits, surveyors looked for what information patients receive at the point of admission; training or education that staff receive for active shooter drills, fire drills, and emergency response drills; and the interpretive services process.
“[Surveyors will] want to see that staff followed the process for providing information in the patient’s preferred language, and followed policies regarding use of family as interpreters,” Peck explains.
All registrars should be able to explain comfortably how they contribute to safe care by following the TJC’s National Patient Safety Goals. Also, registrars should be conversant on fire safety plans for their area, education requirements for their job role, and how they protect patient privacy.
“Surveyors will look to see that patient areas are consistent with safe and high-quality patient care,” Joyce says. For registrars, this includes keeping hallways free of clutter, practicing appropriate hand hygiene, and wearing clearly visible name badges.
“Surveyors will want to see that staff is protecting patient privacy in the workspace and at every interaction,” Joyce adds.
Patient access leaders at Cleveland-based The MetroHealth System continually remind registrars that surveyors will be on the lookout for particular scenarios such as:
- no documents with protected health information are visible;
- patients have received documents such as the Important Message from Medicare form and Patient Bill of Rights;
- forms are offered in the appropriate primary language or interpretive services are offered, if needed;
- for observation patients, a Medicare Outpatient Observation Notice document was signed.
For each of these items, “documentation is key,” says MetroHealth Admitting Manager Kenneth Kirby, CHAM. For instance, if an uncooperative patient refuses to sign a form stating that he or she received information on privacy rights, it could appear later as though the registrar forgot to give it. “You can’t document enough in this type of situation,” Kirby advises.
Surveyors talk to employees who registered or scheduled patients they happen to be tracing. “Preparation from every member of the team is critical to a successful survey,” Joyce emphasizes.
If registration processes are found to be out of compliance in some way, it could result in a requirement for improvement notice for the organization. However, Peck says as long as registrars know their job responsibilities, “then they should have nothing to worry about.”
Joyce finds that to survive a TJC survey, conquering nerves is “half the battle. We stress to our staff that they should relax.” Panic-stricken registrars sometimes try to study requirements at the last minute after surveyors have arrived on site. Yet, registrars already know all the answers because they perform their duties every day. “Surveyors will ask questions to ensure that staff understand their role in providing safe, quality patient care,” Joyce notes.
Hopefully, registrars already are familiar with departmental policies and procedures. In the unlikely event a surveyor throws a curve ball, Joyce recommends designating “a go-to person that you can refer to in the event you don’t know the answer.”
Patients are not fans of robotic-sounding scripting read verbatim; surveyors will not appreciate it much, either. Surveyors would rather hear registrars simply talk about their typical day. Once the word gets out that surveyors are on the premises, panicked reactions are the status quo. Instead, Peck recommends registrars take a deep breath, express confidence, answer questions honestly, and support their colleagues.
“Surveyors are relatively harmless and are here to help us improve,” Peck says. “They will only ask you about the work you do every day.” Still, no one knows all the answers all the time. However, rather than lying, Peck recommends that stumped registrars tell surveyors that they will follow up with their supervisors.
Also, if a surveyor’s spotted talking with a co-worker who may be struggling to answer a question, Peck says that is no time to make yourself scarce. Step over, listen, and learn. “Help your teammate out, just like you would any other day.”
Employees in clinical areas are aware that surveyors from The Joint Commission could arrive at the hospital at any time unannounced. The same is not always true for registration areas. But since registration and admission staff are the first employees patients meet, that means these employees also are the first ones surveyors will approach.
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