eDocTalk article

Here comes The Joint Commission: What you need to know

April 2013

This year, The Joint Commission (TJC) will visit each Legacy Health site for a survey. Are you ready? Review these Q/As to find out.

What do physicians and LIPs need to do to prepare for a survey?

  • Ensure that your licensing, credentialing and privileging is up-to-date with Medical Staff Services.
  • Review the Medical Staff Annual Education: Control infection, manage pain, know your codes!

Will physicians and LIPs be expected to talk to the surveyor?

  • The surveyor may ask you questions about your documentation or regarding the care being provided to your patients.
  • The surveyor may request to observe a patient/family interaction, a procedure or an operation.

What are the key focus areas the surveyor will likely evaluate?

Documentation — All entries must be signed, dated and timed including documents that are scanned into Epic. Potential documentation focus areas include:

    • Consents and H&Ps are completed within the appropriate time frames.
    • Assessments are complete. This is a particular area of focus if you have a patient who is receiving sedation. There must be a completed presedation assessment prior to starting the procedure.
    • Medication Reconciliation is complete.
    • Orders are complete, accurate and authenticated. Be sure to authenticate any outstanding verbal orders.
    • Discharge summaries include your recommendations for follow-up.

Infection Control — Surveyors will be observing for maintaining isolation precautions, hand hygiene and using the appropriate PPE (such as when entering isolation rooms or operating rooms).

Communication — A surveyor may request to witness a physician hand-off or consultation. Surveyors want to see how you are involved with the multidisciplinary care team, and will be looking for evidence of this in your communication and collaboration with others.

These are just some of the potential areas in which your assistance and presence may be requested during the upcoming TJC surveys.

Your normal care for patients

"All of the above tips are simply taking care of patients the way you all know how to do," says Lewis Low, M.D., Legacy senior vice president and chief medical officer.

"Remember," he adds, "if you are asked about policies or guidelines and do not know the answer, it is alright to reply that if you do not know a policy or guideline, you either refer to the intranet or you ask the nursing charge nurse to help you find it."

Thank you in advance for your preparation, diligence and commitment to Legacy and its patients.

If you have questions regarding the upcoming surveys, please contact the Accreditation and Clinical Compliance team at 503-415-5276.

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