Surveyors from the Joint Commission have arrived!

Michigan Medicine anticipates that the Joint Commission visit will last five days and the team of surveyors will visit all clinical areas at onsite and off-site locations. 

The scope of the survey encompasses both inpatient and outpatient venues across all hospitals, health centers and 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 can you contribute to a successful survey?

• Each unit/area will be asked to conduct an immediate self-survey sweep using the appropriate checklist(s) found at http://www.med.umich.edu/i/quality/tools/accredreg/selfsurvey.html. 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 at http://www.med.umich.edu/i/quality/tools/doc/accredreg/selecting_tracer_patients_nursing_tips.pdf
• Clean and de-clutter 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 at http://www.med.umich.edu/i/Safety/FireSafety/Prevention/CorridorClearance.shtml
• Perform proper hand hygiene, as surveyors will be observing this practice. Please review your unit’s data at https://tab.med.umich.edu/#/views/MichiganMedicineHandHygieneCompliance/TrendBreakdownbyRole?:iid=1
• Know and demonstrate the proper Patient Identification process. Review the “Identification of UMHS Patients” policy found at https://michmed-clinical.policystat.com/policy/7118708/latest/
• Keep all medications secured and label medications according to Medication Administration Policy and Procedure at https://michmed-clinical.policystat.com/policy/10464801/latest/
• 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.
• For tips on how to interact with surveyors, review the Wednesday Wisdom found at https://www.med.umich.edu/i/arr/tools/doc/accredreg/wisdom/wisdom_7-20-2022.pdf

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 and more, will be making routine sweeps to identify and remediate issues.
• Managers/supervisors will be rounding in their departments to support their staff & answer questions.

Will you be kept updated on survey progress and findings?

• Zoom facilitated institutional briefings will take place at the end of each day of survey (Monday through Thursday) at approximately 6 p.m. On Friday, an open “Exit” Zoom call will take place approximately at 2 p.m. If the time changes, a follow-up communication will be sent. Zoom links will be shared via email on Day 1 for the daily briefings and Exit conference.
• 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 we can have a successful survey and continue our long history of successful accreditation. Thank you for your cooperation.