Surveyors from The Joint Commission have arrived

March 4, 2019  //  FOUND IN: Updates & Resources

Surveyors from The Joint Commission have arrived and it is anticipated that their visit will last five days. The team of surveyors is expected to visit all clinical areas at onsite and off-site locations.

The scope of the survey encompasses both inpatient and outpatient venues across all hospitals and health centers, as well as Home Care Services.

A large portion of the survey agenda will involve surveyors walking around tracing the care given to patients, inquiring about the care delivery process, observing work practices, and interviewing staff, patients and families.

The survey process will also include a special focus on the environment of care, fire safety issues and emergency preparedness.

How you can contribute to a successful survey 

  • Each unit/area will be asked to conduct an immediate self-survey sweep using the appropriate checklist(s) found here. This should be repeated minimally every day, but preferably several times during the day.
  • Each manager/charge nurse should review the “Survey Tips” for picking potential patients for the surveyors to trace.
  • Clean and declutter all staff rooms and conference rooms, as surveyors will be asking for a private place to go to discuss confidential matters related to patients. Also, clear all egress corridors according to the “Corridor Clearance” requirements.
  • Perform proper hand hygiene, as surveyors will be observing this practice. Please review your unit’s data by clicking here.
  • Know and demonstrate the proper patient identification process. For a refresher, review the “Patient Identification” policies found here and here.
  • Be mindful of the need to protect patient confidentiality as it relates to patient identifiable information that might be visible and any audible discussions about confidential matters.
  • Wear your official U-M ID badge with your name and picture visible above your waist.

What organizational support is available during the survey?

  • A Survey Command Center will be in operation during the entire survey to answer questions and address concerns or issues. It can be reached at 734-763-7439 between 8 a.m. and 5 p.m.
  • Various departments, including pharmacy, infection prevention, EVS, etc., will be making routine sweeps to identify and remediate issues.
  • Managers/supervisors will be rounding in their departments to support their staff and answer questions.

Updates on survey progress and findings

  • An open forum will take place at the end of each day of survey (Monday through Thursday) at approximately 6 p.m. in one of the hospital auditoriums (location to be announced). On Friday, an open “Exit” forum will take place midday (time and location to be announced).
  • Members of AdForum, MPlan, ACU leadership, service chiefs and department chairs should facilitate communications and share pertinent information with their departments, staff and faculty based on:
    • Daily morning briefings (Tuesday through Friday) where they will receive “official” comments directly from surveyors.
    • Evening communications (Monday through Thursday) where they will receive “unofficial” summary of observations from survey liaisons at the end of each day’s survey activity.

With your help, this will be a successful survey and Michigan Medicine will continue its long history of successful accreditation! Thanks for your cooperation.