The Joint Commission On-site Survey

In the EC session the clinical engineering representative discusses the performance of the medical equipment program and answers questions from the surveyor.

The unannounced full survey is another key component of The Joint Commission accreditation process. “Unannounced” means the hospital does not receive an advance notice of its survey date. The Joint Commission started conducting unannounced surveys on January 1, 2006. The exception to the unannounced survey includes situations in which it would not be feasible to conduct an unannounced survey, at the Bureau of Prisons or Department of Defense, for example; and Periodic Performance Review (PPR) option 2 and option 3 surveys (see www.jointcommission.org for more details).

The Joint Commission will conduct unannounced surveys during the first 3 years (2006–2008) in the same calendar year that the survey would have come due under the old 36-month cycle. For example, if the facility’s last survey was sometime in 2005, the survey team can show up at the facility anytime between January 1, 2008, and December 31, 2008. Successive surveys will occur 18 to 39 months after the facility’s first unannounced survey. If, for example, the facility’s first unannounced survey was on January 1, 2006, the next unannounced survey can happen anytime between July 1, 2007, and March 31, 2009.

Survey Planning Session

During this session, the surveyors review and discuss data, select tracers, and plan the agenda for the survey. They review the annual evaluations of the hospital’s seven Environment of Care (EC) (including medical equipment management) plans and the minutes of previous meetings of the safety/EC committee. This session is normally limited to The Joint Commission surveyors.

EC Session

This is the main session where the clinical engineering representative discusses the performance of the medical equipment program and answers questions from the surveyor. The EC includes safety, security, fire/life safety, hazardous materials and waste, utility systems, and emergency management, besides medical equipment. At this session, the representatives from the seven EC areas are present.

See the 24×7 “CCE Prep” for November 2007 here.

Before this session, the surveyor receives input from other members of the survey team on EC-related issues that they may have observed during the survey.

The EC session consists of two portions. The first portion or group discussion consumes about 30% of the allotted time. During this portion, the surveyor will review how the hospital’s approach to the seven EC programs fits with the EC risk-management cycle. The risk-management cycle consists of six phases—plan, teach, implement, respond, monitor, and improve. The intent of this EC session is to elicit discussion from the EC representatives on how the seven areas of the EC are addressed in various phases of the EC management cycle. During this portion, the strengths and vulnerabilities of the hospital in the area of EC are reviewed.

The second portion—observation—takes up approximately 70% of the time and is used to evaluate the organization’s performance in managing the EC risk. The particular risk or process is selected based on the review of the appropriate EC documentation, observation by survey team members, and information from the previous group discussion session. The surveyor assesses the selected process or risk based on its implementation. A tracer may be put into action to assess a particular risk. The 24×7 November 2007 “CCE Prep” article has an example of a tracer.

The EC session concludes with the surveyor summarizing and relaying any probable weaknesses to the hospital staff that are responsible for managing the process or risk. The hospital staff provides information and relevant documentation to address any potential vulnerability.

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Arif Subhan, MS, CCE, is a senior clinical engineer, Masterplan, Chatsworth, Calif, and chair, education committee, ACCE. For more information, contact .