Be prepared for the Joint Commission survey
Sometime between now and the end of March 2016, the U-M Health System will be visited by surveyors from The Joint Commission for an assessment of our entire clinical operation. It is important for all UMHS faculty, staff and students to help our institution get ready and stay read for this unannounced survey.
The Joint Commission findings will determine if our hospitals, health centers, home care operations and other services will once again be accredited – a status that enables us to attract patients, receive payment from insurers, and maintain our medical education program. Meeting national standards strengthens public perception and communicates confidence in our ability to provide safe, quality care.
If you have joined UMHS since March 2013, when we had our last survey, please ask your supervisor how the survey affects your area and what you can do to prepare.
No matter where you work or how long you’ve been at UMHS, please take a moment now to review:
- What to do when a surveyor arrives.
- Each manager/charge nurse should review the “Survey Tips” for picking potential patients for surveyor.
- Tracer Tools & Resources (Conducting mock tracers within your units/areas is strongly encouraged):
- Self-Survey Checklists (Each unit/area should routinely conduct self-surveys to identify and correct problems before a real survey):
- UMHS “Yellow Book” (Policies and information that all faculty and staff should know)
- Pick it Up list (Reduce clutter and improve the environment of care)
- National Patient Safety Goals
During the survey, please pay special attention to these Priority Focus Areas:
(The Joint Commission has told us it will focus on these during the UMHS survey.)
(1) Assessment and Care/Services
(2) Information Management
(3) Equipment Use
(4) Infection Control (including observation of our hand hygiene practices)
(5) Medication Management
(6) Patient Safety
What to expect during the survey:
Unlike prior surveys, it is possible that this survey may be only four days in length. If that happens, the survey may begin on either Monday or Tuesday but we will have a larger cohort of surveyors.
A global email will be sent the morning of the surveyors’ arrival. This will occur on a Monday or Tuesday morning. Items on the internal and clinical homepages will also include important updates and information throughout the week.
To see results from our last The Joint Commission survey in March 2013, and other information about our institution on The Joint Commission’s site, visit http://www.med.umich.edu/i/quality/action/ready.html