by Susie Cymbor, MD
Vizient Physician Accreditation Advisor

The growing use of virtual technology during the COVID-19 pandemic is not just confined to advances in patient care via telemedicine. Companies also pivoted to virtual options to conduct business, including accrediting organizations such as the Joint Commission. During 2020, the accrediting organization suspended most of its onsite surveys from March through May in response to COVID but has since launched offsite (formerly called “virtual”) surveys for many of its accreditation and certification programs.

For those who will be going through an offsite survey, accreditation staff will conduct the same types of activities at a hospital that you would have expected during a previous face-to-face survey, such as reviewing documents, medical records and conducting patient tracer activities. However, survey success in a virtual environment relies heavily on providing access to information, so advance preparation and technology testing is important to ensure a smooth and successful survey.

Here are several strategies to help ensure success for your hospital’s next offsite survey.

Prepare for the document review

For a Joint Commission offsite survey, organizations will be asked to upload required documents to a SharePoint site assigned to your organization prior to the survey. You can start this process well in advance by ensuring current policies and procedures are digitized so that they can be uploaded prior to, and referenced during, the offsite survey. Doing this in advance allows you to review current policies to ensure completeness and accuracy.

For example, if “sterilization” is the policy that is needed for upload and your hospital has separated the components of instrument reprocessing into several policies, gather all the policies that speak to the transport and reprocessing of contaminated instruments. A policy request for “high level disinfection” means that all policies in all departments where high-level disinfection is being performed are needed since processes could be different.

Prepare for virtual reviews

The credentialing and privileging, human resources, and medical record sessions will be conducted by sharing your computer screen during the session. Identify in advance the files that will be needed for each of the sessions along with the appropriate staff members who have permission to access those files. Ensure the appropriate files are digitized, but not uploaded. 

For example:

  • For the credentialing session, have the following file components available: application, requesting and granting privileges forms, required documents, data used to evaluate the provider for granting of privileges and current focused professional practice and ongoing professional practice evaluation information
  • For the human resources session, file components should include job description, required certifications, documents and licensure, performance evaluations, competency assessments and health files
  • During the medical record session, surveyors will review many medical records and identify specific components. Your cadre of expert medical record navigators is vital, especially during multiple simultaneous medical record review sessions. When selecting a location for this session, consider one that allows the ancillary experts to move between stations quickly to provide assistance. Identify and plan for how to quickly access difficult-to-locate medical record components, such as electronic medical record (EMR) documentation imported to the hospital EMR, such as anesthesia records, orders and procedure documentation.

The system tracer sessions are conducted using a Zoom platform. The leadership, emergency management, quality data, infection control and medication management sessions may be combined into one or two sessions. The surveyors will be most interested in tracking and trending of data and how that leads you to improving care. Be prepared to share examples of recent past, current and proactive project summaries.

Plan for technology

Unlike previous face-to-face surveys, an offsite survey is heavily dependent upon the use of technology. Confer with your IT team early to discuss each step of the survey process and your technology needs, including:

  • Whether you are digitizing and uploading documents, participating in a review session, or moving throughout the hospital during the patient or life safety tracer portion, the ability to maintain strong access to the WiFi connection is critical. Work with your IT team in advance to discuss your needs, including specific meeting rooms and areas of the hospital where you will be during the survey process.
  • Discuss what type of computer device(s) you will use to scan and upload files for the document review, to store files and share during the virtual reviews and to use as you move throughout the hospital during the patient and life safety tracer sessions.
  • Consider room configurations, number of staff participating and equipment that would be needed for virtual reviews, such as a video screens, microphones or headphones. The life safety and tracer sessions may require multiple devices and require stable cameras and quality sound while moving.
  • Ensure you have appropriate back-up plans for equipment malfunction.

Practice for success

Practicing for your offsite survey is one of the most important things you can do to eliminate “technology anxiety” and to help ensure success. Conduct a mock survey including all technology and walk through each step of the process to determine roles and identify and address potential problems, including:

  • The ability to scan and upload information, screen share and quickly access records
  • Consider whether virtual reviews will be in a group setting with participants in one room or if individuals will be in their own offices. If in a group setting, will the speaker walk to the microphone and camera, have the camera and microphone brought to her/him or have the microphone brought to her/him as the camera is focused on the whole audience? 
  • For patient and life safety tracers, practice staff interviews with the camera, allowing staff to coach peers in the new process. Consider limiting team members present on the tracers, instead encouraging them to join the session digitally to allow them to interject into the conversation easily.

The command center

Continue to staff a survey “command center,” though the purpose and scope should now include the additional coordination of the technology demands of a virtual offsite survey. Your IT team are new partners in the command center and are vital to assuring a successful survey.

When developing your teams consider two new functions. A moderator that monitors team members getting on and off the calls at the appropriate times and a person that monitors the chat function to coordinate conversations with the surveyor and extended team. If you have multiple surveyors these roles will be needed for each digital call.

Each subsequent survey day your survey team will share their findings. You have opportunities for issue resolution and clarification of findings during the survey. Honing your skills of clarification prevents unwarranted findings in your final report.

It is unclear whether aspects of the offsite survey, if any, will return to face-to-face after the COVID pandemic subsides. Much like advances in telemedicine are becoming the new normal, it is likely that some aspects of the survey process, such as the document review, will remain virtual. However, this issue is rapidly changing. For the most current information, check the Joint Commission website. Also know that Vizient Accreditation Services has resources to help coach, test, and enhance your process. Reach out to me if we can help.

About the author: Susie Cymbor, MD, is a Board-Certified Pediatric Anesthesiologist who provides accreditation and regulatory services to Vizient-member organizations. She conducts offsite and onsite mock surveys/compliance gap assessments, coaching during surveys and delivers education presentations on accreditation and CMS compliance topics.

Published: March 9, 2021