Get the latest scoop on Joint Commission survey

Few bits of information are as eagerly sought after as those provided by access managers who have recently undergone a survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations.

With that in mind, Lynn Weeber, director of admissions at Hennepin County Medical Center in Minneapolis, offers feedback on the Joint Commission’s visit to her hospital in late August. Overall, the survey was the most intense the hospital has had, Weeber says, with a distinct difference in style from previous visits.

Her strongest impression, she says, was of the interviewing skill of the surveyor who spoke with her. "He used a lot of open-ended questions and knew right where to probe," she adds. "He asked direct, detailed questions, and there was much more of an ability to let [the person being interviewed] speak than in the past. He would identify key words in the response and probe further. You might get pulled into another whole area. He was skilled at getting more than he asked for."

The following questions were asked, Weeber says, either in the admitting interview or in a session attended by department heads:

1. What is your staff vacancy factor? Do I need to be concerned that you are working below budget?

2. Has there been a day, or part of a day, when the emergency department was closed?

3. Do you get feedback from your patients about the admitting process?

4. Does information services support you? Do you get the best, the latest in technology support?

5. Over the long run, you probably will see an escalation in patient days. Are you going to build more beds, and are there plans to "re-operationalize" your capacity?

6. If you are going to transfer patients for insurance reasons (because the insurer asks that they be treated elsewhere), what is your process?

7. Do you have a resource scheduling system (an automated way to make appointments) for clinic visits?

Because a patient had filed a complaint related to the Patient Rights and Confidentiality standard, the surveyor delved heavily into the issue of how complaints are handled, Weeber notes. "He looked for an information disclosure form and asked about policy and procedure in that area. He asked how we inform patients of the process for registering complaints."

One strong lesson she took away from the experience, she says, is that "if you have things in your policy and procedure manual, you need to be following them. Don’t have things in writing if it’s not your standard to follow them." If the policy says a form will be signed upon admission, she adds, "then you’d better do it. They really want to hold you to what’s in your policy."

Rather than examine pre-selected patient charts, she says, the surveyor "went to the nursing floor and said, Show me where your charts are,’ and picked out some." During the hour she spent with the surveyor, he did not tour the admitting area or talk to registrars.

One interesting development, she says, is that most recently surveyed hospitals she is aware of — including her own — are consistently scoring about 10 points lower on the Joint Commission survey than in the past.

That can be attributed, she suggests, to a new scoring procedure: "When there is [a violation] that crosses over into another standard, they reduce points in both standards."

[Editor’s note: Lynn Weeber can be reached at Hennepin County Medical Center, 701 Park Ave. S., Minneapolis, MN 55415. Telephone: (612) 347-2238.]