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VUMC’s next Joint Commission survey expected this spring

Jan. 25, 2018, 9:34 AM

Vanderbilt University Medical Center (VUMC) employees should begin preparing now for an important upcoming organization-wide initiative — the 2018 Joint Commission survey, which is expected to take place this spring.

The Joint Commission (TJC) conducts re-accreditation surveys of hospital organizations every three years, with VUMC’s last full survey occurring in July 2015. TJC is an independent, not-for-profit organization that accredits and certifies more than 20,000 healthcare organizations and programs in the United States.

“As with previous surveys, employees can expect an unannounced, five-day survey during which approximately 12 or more surveyors will evaluate VUMC’s compliance with Joint Commission Standards,” said Gerald Hickson, MD, Senior Vice President for Quality, Safety and Risk Prevention.

Compliance will be evaluated through the review of patient records, interviews with patients, leadership and staff, review of policies, procedures and quality improvement data, and through observations of clinical and facilities areas.

Although largely the same, there are a few changes for this year’s survey:

  • Expect surveyors in early spring
  • A new scoring methodology, the SAFER Matrix, employs a “see-it, cite-it” methodology. There will be more citations under this methodology
  • All cited deficiencies will be assigned a single timeframe of 60 days for corrective action, including failures to wash hands

Areas of focus to expect during this year’s survey include:

  • Added emphasis on the assessment of ligature, suicide and self-harm risks
  • Clean and clutter-free environment of care
  • Medication orders
  • High-level disinfection and sterilization
  • Medication and supply storage
  • Documentation of patient education, care plans and procedures

Employees can help to ensure a successful survey by:

  • Continuing to provide high quality care to our patients
  • Removing all clutter (e.g., beds, carts, etc.) from hallways, in front of fire extinguishers, pull stations and medical gas valves
  • Tagging and sending broken equipment to Clinical Engineering for repair
  • Contacting Facilities Management to repair stained ceiling tiles, penetrations and to address dusty air vents, etc
  • Ensuring medications are securely stored and properly labeled
  • Becoming familiar with VUMC policies and procedures and how to find them in PolicyTech
  • Timely and accurate completion of documentation

Beginning Jan. 19, the Accreditation and Standards team will begin hosting Quality and Safety Forums focused on Joint Commission Readiness at the Innovation Center located at 3401 West End Ave.

Forums will be held the third and fourth Fridays of each month until the survey and will provide participants with information necessary to prepare. Staff can register for a forum by contacting Jana Cross at

The Accreditation and Standards team will also begin its “Survey Sparks” newsletter to provide tips and other readiness information and will continue to work with our Joint Commission Consultant to perform mock surveys throughout VUMC.

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