Do you have a ready-to-go list?
Having your ready-to-go list assembled at the start of your survey can help your survey run smoothly, according to The Joint Commission.1 (See list for Accreditation Association for Ambulatory Health Care, below.)
The ready-to-go list includes information and documents that should be available for the Preliminary Planning Session and Surveyor Planning Session, both of which typically occur on the first day of survey. The items include:
- performance/quality improvement data;
- infection prevention and control surveillance data;
- infection control plan;
- environment of care management plans and team meeting minutes;
- organization chart;
- list of all sites eligible for survey;
- list of contracted services;
- list of patient appointment schedules or surgery schedules for each survey day.
The complete ready-to-go list can be found in the Accreditation Handbook for Ambulatory Care posted for surveyed organizations on The Joint Commission web site. It is also included in the handbook for office-based surgery practices. In addition, the list appears in the Survey Activity Guide posted on the Joint Commission Connect extranet. It is called the Document List in the Table of Contents.
"The list helps surveyors tailor the survey to the organization and helps us be more effective and efficient," says Angelica Flores, MD, Joint Commission ambulatory care surveyor. "The purpose of a survey is to help the organization identify risk points which might lead to compromised safety. The more prepared the organization is, by making these documents available, the more we can help during our short time there."
This list is especially important if the organization is complex, Flores says. "If I have to spend my time trying to locate the required elements of a plan to determine whether the organization even has a complete plan, there is less time to review a plan e.g., an infection control plan in the context of an organization's unique characteristics, and therefore, less time for education."
How critical is it for the organization to provide the ready-to-go list?
"Surveyors can manage the survey without the ready to go list, but missing documents might lead to something being found non-compliant when it really wasn't," Flores says. "This can be cleared through clarification at a later date, but it is more work for the organization. More preparation will produce a better survey."
Reference
- The Joint Commission. Have your ready to go list...ready to go. Ambulatory Advisor 2011; 1. Web: http://www.jointcommission.org/assets/1/18/AA_Issue_1_2011.pdf.
Documents wanted for AAAHC survey Michon Villanueva, assistant director of Accreditation Services for the Accreditation Association for Ambulatory Health Care (AAAHC), suggests that facilities going through accreditation with their organization have the following documents available for surveyors. This list is not intended to be comprehensive. Items that surveyors would look for include:
During the survey, members of the survey team will provide the organization with their selection from credentials records, personnel records, and clinical records. |
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