CHPR: Please start by describing the Joint Commission and why its visits are important.

Dr. Cheung: The Joint Commission is an entity that is contracted by hospitals to perform site visits for them and on behalf of the Centers for Medicare and Medicaid Services (CMS). About 80% of hospitals in the country are surveyed by the Joint Commission (www.jointcommission.org). They come onsite roughly every three years. Importantly, they arrive unannounced. They give you a window, but you don’t know what day they’ll show up until that day happens. Joint Commission accreditation is very important because CMS accepts the findings of the Joint Commission as their own findings. CMS can always come back and perform what’s called a validation survey if they feel like something was missed or want to do a spot-check audit, but if they accept the findings of the Joint Commission survey, the hospital will then have both Joint Commission and CMS accreditation. Why is accreditation important? Because CMS provides government funding, and if your facility doesn’t have CMS approval, it’s very difficult to get reimbursement from government payers as well as from commercial payers as they tend to follow suit. Accreditation is also a demonstration to the public of the hospital’s high safety and quality standards. 

CHPR: How does the Joint Commission develop its standards?

Dr. Cheung: They actually are a think tank as well as an accreditation organization. They have a group of folks who survey the latest in quality standards from different organizations, including CMS, and use input from surveyors coming back from site visits to help them develop new standards around quality of care and environmental safety. That is how they generate many of their National Patient Safety Goals and other standards. They also seek input from health care professionals via their website, where you can read and comment on proposed changes to standards (www.jointcommission.org/standards/standards-field-reviews/). In fact, just recently there were proposed updates to restraint and seclusion requirements for behavioral health care that were open for comment until April 2024. 

CHPR: What does a typical day look like for staff during Joint Commission visits?

Dr. Cheung: Staff can expect to be stopped at any time by a surveyor and asked questions, like about policies and procedures that they would generally be expected to know.

CHPR: I know my fellow staff members, and I still get nervous about being stopped and asked questions! 

Dr. Cheung: Surveyors generally know that staff might not be 100% knowledgeable about every single policy and procedure they might ask about. It’s important to realize that the Joint Commission takes a very collaborative approach. It’s supposed to be a constructive process of helping the hospital achieve the highest levels of quality of care and adherence to policy rather than a “gotcha” situation. So, staff should answer to the best of their knowledge, and if they don’t know something, they should indicate where they would go to seek that information. 

CHPR: Right. How should hospitals prepare for a Joint Commission visit to ensure a successful outcome?

Dr. Cheung: Hospitals often talk about being “survey ready” in the months leading up to the anticipated arrival of the Joint Commission, and in many ways, they should aim to be “survey ready” all the time. This means all of their policies are fine-tuned and up to date; staff are educated regularly on common and important policies and procedures; the environment of care is inspected regularly for patient and staff safety issues (such as fire safety, ligature risks, infection prevention, etc); documentation by physicians and all staff meets the Joint Commission’s requirements; emergency protocols are in place; and staff personnel files are up to date and accurate. Hospitals should maintain good records of all the inspections and safety measures they perform and keep track of quality improvement efforts they pursue, as the Joint Commission will be interested to hear about those initiatives when they arrive.

CHPR: How does the Joint Commission decide which areas to review in a hospital?

Dr. Cheung: The Joint Commission has a rather exhaustive set of standards covering all aspects of hospital operations, from clinical care and medical records to the safety of the care environment, including fire safety, infection control, and medication management. They cover every single thing, every component that a hospital does in its day-to-day work, as well as the maintenance of records and staff credentialing. Frequently, hospital staff will encounter a surveyor during a patient tracer. In a patient tracer, surveyors basically walk through every step from the patient’s entry into the hospital system until the patient’s current point of care. They look at all of the patient’s medical records as well as interview staff who are taking care of the patient, plus they interview the patient as well. Surveyors will want to be sure that they obtain tracers from all the areas of the hospital’s licensed programs. If a hospital has an adult inpatient unit, child adolescent unit, and partial hospital program, surveyors would perform tracers in each of these areas.

CHPR: Yep. I have participated in patient tracers. What else do surveyors look at?

Dr. Cheung: Surveyors also ask about whether the hospital has had any deaths under their care. They look very carefully into the cause of the patient’s death and the way the hospital performed its root cause analysis to identify any areas that could be improved to avoid a future death or harm to patients. They used to ask for things that were called sentinel events, which is a patient safety event that results in death, permanent harm, or severe temporary harm, but they seem to have consolidated their focus to patient deaths in our recent experience. 

CHPR: What is the background of typical surveyors?

Dr. Cheung: They’re from a variety of backgrounds: nurses, sometimes social workers, and increasingly MDs as well. But for the environment of care component, which is called the life safety survey, the Joint Commission sends out a surveyor with an engineering background who goes around the hospital and even up into the ceiling and the roof—any and all areas where there is mechanical infrastructure—looking at fire alarms and sprinklers, the temperature of water, refrigerators, fixtures on the walls, plugs and outlets, etc.

CHPR: So, how many surveyors are involved in a site visit?

Dr. Cheung: For a hospital of our size (74 inpatient beds and eight partial hospital or intensive outpatient programs), they send four surveyors—two for inpatient, one for partial hospitalization and intensive outpatient programs, and one life safety ­surveyor.

CHPR: How long do Joint Commission visits usually last?

Dr. Cheung: They generally range from two to four days, depending on the size of the hospital. Our hospital’s surveys last three days. And the surveyors do a certain number of patient tracers proportional to the number of patients in the hospital.

CHPR: At the end of the survey, how does the hospital get feedback?

Dr. Cheung: The surveyors provide feedback all along the way. Having a good relationship and open dialogue with the surveyor from the get-go is very helpful. It helps the hospital to identify and rectify areas of concern right then and there. The surveyors are receptive to correcting certain things on the spot—for example, if a given policy does not align with the Joint Commission’s standards, the hospital may have an opportunity to update it and show the surveyors the revised policy. At the end of each day the surveyors give feedback, and then the survey concludes with a closing session that lasts 30–60 minutes when the surveyors review their draft report. This report is finalized and delivered approximately two weeks after they leave. The hospital then typically has 60 days to complete any corrective actions.

CHPR: How does the Joint Commission communicate its findings in this report? 

Dr. Cheung: They use the Survey Analysis for Evaluating Risk, the SAFER matrix, to communicate feedback (www.tinyurl.com/2s36nk4a). This matrix is organized into a three-by-three grid that evaluates the likelihood of harm (low to high) and the scope of a problem (limited to widespread). Each deficiency is clearly marked on this matrix, showing the specific standard that was breached, its severity, and the area of concern. Hospitals then address these pinpointed areas in their corrective actions. It’s a very transparent process. (Editor’s note: See box for a sample site visit finding with matrix.)

CHPR: Can hospitals appeal findings or citations from a Joint Commission survey, and if so, how?

Dr. Cheung: Typically, hospitals will work collaboratively with the Joint Commission to clarify or otherwise work through findings or citations that the hospital leadership does not agree with. Often this means discussing different ways that a corrective action could take place to address a finding. If there is a negative determination or denial of accreditation, there are processes for the hospital to appeal and have the decision reviewed.

CHPR: Are Joint Commission visits ever more frequent than every three years?

Dr. Cheung: Visits can happen sooner if there are multiple violations or evidence of problems that surveyors want to check in on more quickly, or if the hospital has been granted conditional accreditation pending a follow-up survey.

CHPR: If there is one metric that didn’t do as well as others, will surveyors focus on that measure during their next visit?

Dr. Cheung: Yes. Surveyors stay abreast of a hospital’s prior evaluations and areas that were deficient to be sure they’ve been corrected. There also may be national trends that surveyors have a focus on at a certain moment. An example is infection control and prevention in the wake of the COVID-19 pandemic, including evaluating hospitals’ adherence to protocols for hand hygiene and use of personal protective equipment.

CHPR: Are there specific areas where psychiatric hospitals tend to do worse than others?

Dr. Cheung: In our experience, certain compliance areas can present more challenges. Expiring supplies is a common issue. Most hospital goods have an expiration date and shouldn’t be used for patient care after that date even if there’s relatively low likelihood of causing harm, like an expired bandage, dressing, or topical ointment. Fire safety and environment of care issues also tend to be problematic. Hospitals often struggle with keeping corridors and egress pathways clear from obstruction. They can get really congested with equipment and belongings, which can wind up in the wrong place and create a fire hazard. You might remember a time when the Joint Commission was very intent on scrutinizing potential ligature risks to prevent suicide by hanging. Many of us who work in hospitals across the nation thought the scrutiny was a bit excessive, so I am glad that it has been scaled back a bit. But assessing ligature risk remains a routine part of their investigation, checking for places where patients can hang themselves and what hospitals have done to mitigate the risk.

CHPR: We have certainly addressed ligature risks at my hospital, like modifying doorknobs. Are there any recent changes in Joint Commission standards that hospital psychiatrists should be aware of?

Dr. Cheung: Over the last decade, there’s been a focus on enhancing health equity and diversity standards across health care facilities, and the Joint Commission has been right on par with this trend by introducing new standards in recent years. They have also reinforced some of their workplace violence standards by focusing on hospitals’ efforts to manage safety and security risks, efforts to monitor environmental risks (occupational illnesses, staff injuries, patient injuries, damage to property, utility system failures), staff education on workplace violence and reporting processes, training in de-escalation, response to emergency incidents, and leadership engagement to create and maintain a culture of safety (www.tinyurl.com/yc2xrdv3). Those are probably the two most prominent things that are going on right now.

CHPR: Do hospitals have staff assigned to stay on top of all the Joint Commission metrics, including any new ones? 

Dr. Cheung: Yes, hospitals typically have quality management divisions that help them stay on top of all of this stuff. They are commonly in contact with the Joint Commission when they need some support, advice, or resources, or to see if the hospital is on the right track with making a correction or improvement. The Joint Commission is typically very responsive when a hospital has a question about a standard or needs help making a correction or wants to improve in a certain area. And during the visits, hospitals assign a support person for most of the survey to help surveyors get into the different places that they need to access, like medical records.

CHPR: I am sure there is a big sense of relief when the survey is all done.

Dr. Cheung: Yes. Even though it is collaborative, it always feels like taking a test. 

CHPR: Thank you for your time, Dr. Cheung.