Recent Joint Commission Survey?

[cbaldwin 51]

Has anyone been recently surveyed by the Joint Commission?  We are expecting a survey in May, I am preparing for it, and I wondered if there were any trends this year in what they are “observing”.

 

I am responsible for a small transfusion service in a 26 bed rural hospital.  I am checking that documentation for reagents, QC, competency, training, proficiency testing, and patient testing is complete.  I’m updating my P/Ps, and going over the QSAs.

 

The Joint’s observations in 2017:

1.       Not labeling uncrossmatched O negative units with patient’s name, DOB and MRN during traumas. (QSA.05.10.01)

2.       Not periodically reviewing with our medical staff information regarding our BB inventory.  (QSA 05.02.01) (The inspector explained that a new physician unfamiliar with our BB inventory could start a procedure that required more products than we have. The procedure could fail because of inadequate blood products, resulting in possible patient death and legal action)

3.       Not always having the time of signature on transfusion consent forms— “in 3 of 3 consents for transfusion documents reviewed, the time of the patient consent had not been recorded.” (QSA.05.17.01)

4.       Not readjusting the set point to simulate a high alarm when doing quarterly checks on our plasma thawer alarm.   Biomed was checking the alarm, but not simulating a high alarm as the manufacturer requires.  (DC.02.04.03)

 

Around the time of the 2017 survey I remember others on BB Talk mentioning that they were cited for not labeling Uncrossmatched O negative units.  That observation caught me by surprise.  My reactions to the other observations were…well, I should have known better.  We have a lot of traveling MDs and communicating with them regarding our inventory is very important.  And I should have read the plasma thawer operator’s manual more carefully.

 

I’m just wondering if surveyors are concentrating on anything in particular this year….

 

Thanks!

 

Catherine

[Cliff 356]

I've been doing this for a few hundred years now, this is only my opinion, but it depends on the person / people you get.

One thing that is different this time, they are using their Safer Matrix.  Also, there is no longer a "we saw it three times, now it's a citation" pattern.  They are issuing citations for single observations, so you'll likely have more citations than prior surveys.

[John C. Staley 974]

18 hours ago, Cliff said:

 this is only my opinion, but it depends on the person / people you get.

I have found this to be true regardless of the inspecting/assessing agency.  Whenever you are dealing with people personal bias will be involved at one level or another.  Some are better at controlling it while others make no effort in that direction.  Good luck with your inspection. Do the best you can to prepare but always remember.......  They can't kill and eat you, it's against the law.  

[AMcCord 1,101]

And you will fix what they cite - no worries. They expect to find things to cite you for, so don't plan on going through the inspection w/o getting nicked for something, Do the best you can, but don't be hard on yourself when you are cited. Look at it as a learning experience and an opportunity for improvement.

[JoyG 28]

Agree with all the responses!