Get ready for a Joint Commission survey

Medical staff leaders are not always comfortable talking with Joint Commission surveyors, especially if it is their first time involved as a leader.  Frequently, medical staff leaders asked to talk to surveyors today may not be the same leaders from previous surveys.  The key to being comfortable is being prepared.  Preparation should include:

·         Reviewing your own processes (i.e., bylaws, rules and regulations, credentialing process, and peer review process)

·         Knowing what the surveyors are likely to ask

·         Practicing with experienced leaders

Leaders should understand how the medical staff works.  Know your bylaws, which is the medical staff’s constitution, and how the bylaws operate through rules and regulations and other documents such as the peer review policy.  Know how your credentialing process works from receipt of an application to the final grant of privileges by the board.  Know how peer review information is used to create objective measurements of competency that can be used in the credentialing process.

Know what the surveyors are likely to ask.  A good place to start is the 2012 Survey Activity Guide by The Joint Commission.  Medical staff leaders should check out the section on leadership and the section on medical staff credentialing and privileging.  Surveyors will ask for bylaws, rules and regulations, MEC minutes, peer review and focused monitoring records.  They want to see the link between peer review and the re-credentialing process.  They will want to look at credentialing files, particularly those in high-risk specialties, non-physician practitioners, moonlighters, hospitalists and low-volume providers.

Another thing surveyors like to look at is whether previous findings have been resolved.  Go back to your last survey and see what findings were present, ask how they were dealt with, and check to ensure that they were resolved.

Finally, practice with other leaders and quality staff who have gone through the process before.  Familiarity with the survey process and potential questions will be well worth the time spent by eliminating the fear of the unknown.

Mary J. Hoppa, MD, MBA, is a senior consultant with The Greeley Company, a division of HCPro Inc. in Danvers, MA.