Ambulatory Care Accreditation Survey Activity Guide - The Joint Commission

Ambulatory Care Accreditation Survey Activity Guide

January 2021

Survey Activity Guide for Ambulatory Care Organizations

January 2021

What's New?

New or revised content is identified by underlined text.

Changes effective January 1, 2021

? Surveyor Planning Initial ? This activity has been eliminated for all programs. NOTE: Surveyors will need as many documents as possible from the program-specific Document Lists available for the Surveyor Arrival and Preliminary Planning activity.

? Special Issue Resolution and Surveyor Planning/Team Meeting ? Special Issue Resolution takes place throughout the survey; that is, surveyors do not typically wait to address issues until a scheduled time on the agenda. Therefore, these activities will now occupy the same 30-minute timeframe on the survey agenda and either one or the other activity will be conducted by the surveyor based on need. Surveyors will inform the organization which activity will take place.

? Survey Activity List ? Updated to clarify applicability of the Life Safety Code? Building Assessment activity.

? Life Safety Code? Building Assessment ? Specified the NFPA editions that are being surveyed.

? Behavioral Health Care and Human Services Accreditation Program Document List and Survey Activity List ? Updated to reflect the change in the accreditation program name.

? Laboratory Accreditation Program Document List ? List reorganized and one new item included

? Sample Survey Agendas ? Updated to reflect elimination of Surveyor Planning Session, combining of Special Issue Resolution and Surveyor Planning/Team Meeting activities into same time slot, and Ambulatory Surgery Center, sample two-day agenda reflects changes in the Life Safety Surveyor schedule of activities.

? Ambulatory Surgery Center Life Safety & Environment of Care Document List and Review Tool ? Tool has been expanded to include additional environment of care related documents for review.

? Imaging Document Review Guide ? Introducing a new tool to help organizations compile imaging services documents and data needed for surveyor review, based on the imaging modalities provided by the organization.

Copyright: 2021 The Joint Commission

AHC/OBS Organization Guide January 2021

Ambulatory Health Care and Office-Based Surgery Organizations Survey Activity Guide (SAG) Table of Contents

How to Use this Guide Prior to the Survey Preparing for Surveyor Arrival Survey Readiness Guide Survey Document List Survey Activities During the survey Surveyor Arrival and Preliminary Planning Session Opening Conference Orientation to Your Organization Individual Tracer Activity Special Issue Resolution Surveyor Planning/Team Meeting Daily Briefing (applicable if survey is two or more days) Competence Assessment and Credentialing & Privileging Environment of Care and Emergency Management Session Life Safety Code? Building Assessment System Tracer-Data Management Clinical Leadership and Staff Discussion ? Bureau of Primary Health Care only Governance Discussion Session ? Bureau of Primary Health Care only Leadership Session Surveyor Report Preparation CEO Exit Briefing (Optional) Organization Exit Conference Following the Survey What Happens After Your Joint Commission Survey Appendix Table of Contents Behavioral Health Care and Human Services Accreditation Program Document List Behavioral Health Care and Human Services Accreditation Survey Activity List Laboratory Accreditation Program Document List Laboratory Accreditation Survey Activity List Tips for Conducting Mock Tracers Program Specific Tracer ? Continuity of Care System Tracer ? Infection Control System Tracer ? Medication Management Sample Survey Agendas Ambulatory Surgery Center Life Safety and Environment of Care Document List and Review Tool Imaging Document Review Guide

Page Number

4

6-7 8 9-11 12-13

15-16 17

18-20 12-23

24 25 26 27-28 29-32 33-34 35 36-37 38 39 40 41 42

44-45

47 48 49-50 51 53 54 55 56 57 58-64 65-77

78-80

Key: The following abbreviations are used throughout this Guide to identify specific accreditation programs and the survey activities applicable to the program. ? AHC ? Ambulatory Health Care (surveyed from the Comprehensive Accreditation Manual for Ambulatory Health Care and not

the Hospital Accreditation Manual) ? OBS ? Office-Based Surgery (surveyed from the Comprehensive Accreditation Manual for Office-Based Surgery and not the

Ambulatory Care Accreditation Manual)

Copyright: 2021 The Joint Commission

AHC/OBS Organization Guide January 2021

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