With The Joint Commission (TJC) and other accreditation organizations moving to more virtual surveys in the wake of the Covid-19 pandemic, many hospitals are scrambling to prepare their documentation for a virtual world. These accreditation visits are crucial to hospitals that require successful surveys in order to receive funds from the Centers for Medicare and Medicaid Services (CMS), a major source of revenue for almost every hospital.
Due to the impacts of Covid-19, TJC and other accreditation firms plan to incorporate physical distancing measures and some remote working technologies into their process. In doing so, they will be more reliant on sharing of virtual documents during accreditation surveys. As this article from Facility Executive points out, many hospitals are not prepared for this:
“A survey conducted during the webinar discussion revealed:
- 50% of attendees are not prepared at all for virtual document review sessions conducted by hospital accreditation surveyors including The Joint Commission
- 33% of attendees said that preparing for virtual surveys would take a lot of work, but they could do it
- 8% of attendees said they would be mostly prepared, but it would take some work
- 8% of attendees said that preparing for a virtual survey would be no problem because all their files are digital and organized
“Surveys are done in person for document review and inspections where hundreds of codes and related documentation are reviewed to ensure compliance. The pandemic is compelling us to look for alternatives such as experimenting with virtual surveys.” said Suri Suriyakumar, CEO of ARC Facilities, who co-led the webinar with Dennis Ford of Atrium Health.
According to Ford, who handles corporate support services, plant operations & management at Atrium Health, there are several administrative bottle necks associated with binders. While binders are pretty much the standard at hospitals, the organizing and updating process slows down when a system of multiple hospitals are surveyed under the same license and must follow the same policies and procedures. When one binder is updated, all must be updated at each individual hospital.
…Surveyors are impressed when proper documentation is provided quickly and is associated with each regulatory requirement. If anything is missing, out-of-place or does not contain required information, then the survey may begin with findings, which will set the tone for the rest of the visit.”
Read the entire article here: Are Hospital Facility Managers Prepared For Virtual Surveys?
The possibility of more remote or partially virtual surveys will result in additional scrutiny on electronic documentation around patient safety collected by hospitals. Is your hospital ready to share electronic documentation, such as tracer logs, with TJC? To prepare, hospitals have to make sure that they are following all of their detailed processes all of the time. Any breakdown in your processes would show in the documentation, putting your hospital’s reputation and finances at risk. Consider automation tools that help track the processes that TJC and other accreditation agencies focus on during their inspections. Systems such as iRIScope and iRISecure have been developed to ensure that processes and protocols are being followed with Endoscope and Tissue documentation, respectively, since your managers can’t watch over every step of the way.