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How to prepare for a successful joint commission survey

By Michael Connors, PT, DPT, PhD

The name Joint Commission tends to strike fear into the hearts and minds of practice owners and rehab managers.

However, this fear is largely unwarranted as most don’t understand the true purpose of a Joint Commission survey. The survey is not meant to be punitive in nature but rather designed to emphasize a high level of service and quality to maximize patient safety during all health care interactions in a facility.

A successful Joint Commission survey will be short and swift and successful if you put in the time to prepare in advance to ensure your practice is meeting all of the standards for an outpatient facility. There are a myriad of standards, but some careful planning on your part can ensure a higher likelihood of a successful survey. It is best to start planning six to 12 months out from the expected date of your site survey. You will want to ensure you have all of your quality and compliance elements of your practice in order to ensure a successful survey outcome.

First, start with the end in mind! Take the time to become acquainted with the Joint Commission standards for outpatient physical therapy. These standards are different than inpatient PT and can also slightly differ for freestanding outpatient clinic sites (i.e., site located off the hospital campus). If the task seems too daunting to tackle alone, there are a multitude of consultants that specialize in preparing outpatient clinics for these surveys.

Next, start to organize your quality and compliance information in an easily accessible place, such as a binder. When a Joint Commission surveyor is in front of you and requests a piece of information, you want to confidently provide it to them without scrambling to find a missing document. Taking the time to organize on the front end will tremendously improve the likelihood of having a successful survey. So, what are the types of things that a Joint Commission surveyor is concerned about in an outpatient physical therapy clinic? After all, we aren’t performing surgery in outpatient therapy, so what could they possibly focus on?

There are a few key items that Joint Commission surveyors concentrate on in the therapy world aimed at maximizing patient safety in the environment. A large part of the survey focuses on the environment of care, or simply put, the environment that patient care takes place in. Examples include:

  • Cleanliness of the facility
  • Physical space is free of obstacles
  • Exits are clearly marked and free of clutter
  • Annual maintenance and yearly checks/calibrations occur on all equipment
  • Stools and treatment tables are free of cracks (infection control issue)
  • Daily temperature checks are done on hydrocollator, paraffin, splint pans, etc.
  • Regular hand hygiene occurs before, during, and after patient contact
  • Treatment surfaces are properly and regularly cleaned in between patient use

In addition to the environment of care, the survey will also evaluate how your practice ensures you provide treatment to the appropriate patient. It is commonplace to utilize two patient identifiers to ensure treatment is provided to the correct patient. The most common patient identifiers are name and date of birth. The surveyor will want to witness your patient intake process to ensure you are identifying patients from the time they set foot in your office. Aside from the intake process, the surveyor may ask your employees random questions, so it is also imperative to educate your staff so that everyone is on the same page.

Finally, the survey will also include a chart review. The questions surrounding the chart review are to ensure that all patients are treated equitably and that there is no cookie cutter approach to patient care occurring in your practice. A surveyor will want to look at a specific diagnosis and inquire as to how the plan of care for that patient is unique to their specific presentation. This is not an involved assessment but merely a check and balance system to ensure a level of specificity is occurring unique to a patient and their plan of care.

Joint Commission surveys can be a daunting process for an outpatient therapy clinic. The key to a successful survey is to be organized and prepared.


Mike Connors

Mike Connors, PT, DPT, PhD, is a PPS member and regional director of therapy for Greater Therapy Centers in Bedford, Texas. He can be reached at mconnors@gtc-pt.com and @mconnorspt.