The Joint Commission Surveyor Presentation

What will The Joint Commissions be looking for on your next survey? 

I had the opportunity to attend the Alaska Association of Medical Service Professionals 10^th Anniversary Conference held in Soldotna, AK on June 11-13.  One of the speakers was a physician surveyor for The Joint Commission and he shared with us what surveyors will be reviewing the next time around. 

At this point in time we are still uncertain of the impact MS.1.20 will have on our medical staff offices as to the Elements of Performance that may affect our medical staff bylaws.  MSPs hope that we will not be required to include the details of the credentialing and privileging procedures in the bylaws but be allowed to house those in appropriate policies and procedures. 

One thing is certain; there will be a totally new numbering system for all the standards.  I’m considering myself fortunate that I did not memorize all the current numbers or I’d be on brain-overload by December 2009.  The 2009 standards will be available on-line at TJC’s web site by September 2008.  I have been assured that there are NO new standards only a more logical flow in the new format. 

Here are some of the key elements that surveyors will be looking for on the next survey: 

1. Privileges

If your facility is using “core” privileges, there must be a listing of what is included in that grouping.  Those physicians who wish to delete a core privilege must be allowed the opportunity to do so by crossing it out. 

2. Health Statement

Applicants will still make a statement regarding health status and any problems that could affect his/her ability to perform a specific privilege BUT that must be confirmed (each facility will determine how this will be implemented). 

3.  Focused Professional Practice Evaluation

Is there a clear description of the process for FPPE for new privileges, both for initial requests and for new privileges?   Is the trigger criteria clearly defined?  Is the proctor plan in place with appropriate documentation? 

4. Focused Professional Practice Evaluation

Is there a clear description of the process for FPPE for new privileges, both for initial requests and for new privileges?   Is the trigger criteria clearly defined?  Is the proctor plan in place with appropriate documentation? 

Those are the highlights from my notes.  The more I hear about these standards, the more I start to understand it.  And that makes me just a little nervous … am I really getting this? 

I shared this information with my Chair of our Credentials Committee and his response was, “Well, that’s one surveyor’s viewpoint”. 

I wish us all the best on our next surveys and I’m keeping my fingers crossed that I won’t be the first! 

Carole  La Pine, MSA, CPMSM, CPCS