How to Maximize the Value of Your Joint Commission Mock Surveys
Kristin Pitocco | April 25, 2023
A mock survey can be an invaluable preparation tool for healthcare facility and environmental health and safety (EH&S) managers as they prepare for Joint Commission triennial accreditation surveys or other certification reviews. By allowing an expert with a fresh set of eyes to audit your facility, it becomes much easier to identify and close any compliance gaps well before your survey date.
The challenge, however, is that not every fresh set of eyes will bring the same value to this process. Working with the right partner can prove essential in understanding upcoming areas of survey focus and the best solutions to potential compliance deficiencies.
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Why survey experience matters
A mock survey’s value lies in getting a new perspective on your facility’s compliance and, in theory, anyone with the right review tools can provide this support. Each year, The Joint Commission updates its Life Safety & Environment of Care Document List and Review Tool to guide hospitals in preparing their documentation for review. It publishes lists of the most challenging requirements to meet, encouraging healthcare organizations and their mock survey partners to focus attention on these critical areas. Even with these resources at hand, however, not all surveyors will be able to provide the same level of insight in helping facilities prepare for their next survey.
By working with a partner who meets the four qualifications listed below, facility and EH&S managers can better ensure their hospital’s compliance.
1. A comprehensive approach
The Joint Commission’s Environment of Care, Life Safety, and Emergency Management standards cover a broad amount of ground. No matter how well versed in the technical details are the individuals tasked with maintaining compliance with these standards, the ongoing evolution of both buildings and standards can make it difficult to keep up with everything.
The same can be true when working with a mock surveyor who may have experience solely in one aspect of the environment of care—for instance, a former facilities manager or director that has excellent knowledge of the utilities standards, but significantly less knowledge when it comes to medical equipment standards. These partners are more likely to turn their attention to the areas they know well, overlooking some potential deficiencies. This is why it’s beneficial to work with a mock survey partner who can bring to this experience a breadth of knowledge that encompasses the many areas to be targeted during a survey.
2. Has their finger on the pulse
Recent survey experience counts for a lot when it comes to maximizing the value of your mock surveys. As new standards are released or certain areas appear more commonly prone to deficiencies, Joint Commission surveyors may adjust their focus to call attention to these areas. By working with a mock survey partner that regularly has the opportunity to participate in actual survey events, healthcare facilities and EH&S managers gain the advantage of insight into today’s Joint Commission priorities.
For example, in July 2021, The Joint Commission implemented new life safety standards for business occupancies, such as freestanding outpatient clinics and medical offices within hospitals or other healthcare buildings. Early on, the addition of 29 new elements of performance seemed overwhelming to many facilities and EH&S managers, and it wasn’t clear how this would affect the survey experience.
In sites where we had staff members embedded and participating in the survey process, we were able to quickly determine that the biggest new challenge facing clients as a result of the new standards was an increased focus on inspection, testing, and maintenance documentation for offsite locations. We were able to use this insight to advise other clients awaiting survey to look closely at how they organized inspection, testing, and maintenance documentation relevant to their business occupancies.
3. Able to connect planning to implementation
For an even more comprehensive approach to your mock survey, it can help to select a partner that can identify and then provide advice on how best to solve potential compliance gaps. It’s one thing to understand that a specific system may not be in compliance; it’s another thing entirely to develop and apply an appropriate fix. This is particularly true when it comes to working with new standards or emerging areas of emphasis.
By working with a mock survey partner focused on hospital environments day-in and day-out, facilities and EH&S managers get the benefit of understanding what solutions to implement to move forward. A good partner can provide insight into the practical solutions that have proven effective in other facilities so there is no need to reinvent the wheel.
4. Is available for long-term support
Your surveyor will become familiar with your organization through the mock survey process, and this has value to a healthcare facility even after the survey event is over. This partner can serve as a resource in the event of potential findings during actual survey events.
Working with a partner well-versed in your site and the survey experience can make a difference during an actual survey event. Having an ongoing relationship with a mock survey partner who is familiar with your organization can give you another tool in your arsenal when deficiencies are noted by an actual surveyor. Having a consistent partner with whom to discuss findings and issues during an actual survey event can boost confidence to push back against unwarranted survey findings. Even if a deficiency is determined to be legitimate, a mock survey partner who can pull from recent experience around similar issues at other facilities can also guide a more effective response process.
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Get the most out of your mock survey
To get the most value out of a mock survey, it’s important to conduct this exercise well in advance of your expected survey date—at least six to eight months prior. This allows time for any needed improvements. A best practice is to perform a mock survey annually to keep your facility in a continuous state of readiness. After all, this strategy is about far more than simply checking a box—it’s about ensuring patient safety.
EH&E’s comprehensive approach to healthcare facility safety has helped numerous healthcare facilities managers prepare for their Joint Commission surveys. Our team works closely with health systems throughout the Northeast in ensuring compliance. If you’re ready to take a more comprehensive dive into your facility’s compliance, contact EH&E today.