Fun With the Joint Commission

Our industry has many regulatory and accrediting organizations, including the Department of Health, DNV, and The Joint Commission to name a few. Meeting the requirements imposed by these organizations is part of our daily activities, however when these organization come in it is always a little stressful. We recently had our Joint Commission inspection and I would like to share our experience with the survey.

Anyone who uses The Joint Commission as their accreditation body knows that their surveys are unannounced. Once in the survey window they can show up at any time to survey the hospital, this is done to encourage facilities to ensure a constant state of readiness and compliance. Our three-year anniversary date was closing in and we were expecting them any day. We were told our survey this year was going to be just three days however they were sending five surveyors. It was funny to hear the prediction on when they were coming as if someone knew the secret to their schedule. Most of us had concluded that if we made it past Tuesday in any given week our survey would not be happening that week. We rationalized that they certainly would want to keep Friday free as a travel day given our location to major airports.


I was scheduled to present at the MD Expo in Connecticut on October 6, my plan was to work in my office Monday and Tuesday and drive up Wednesday once the “coast was clear.” I had warned the MD Expo staff that I may have a conflict if TJC came, and we prepared a back-up plan. Tuesday came and went, we all felt we were in the clear for that week, I informed the MD Expo team that I was on my way and was excited to see them. I started my drive to Connecticut at 6 a.m. and was just settling in for a 70-mile stretch of highway when my cellphone rang. It was our compliance executive and when I answered the phone all she said was “they’re here” in the tone from the 1982 movie “Poltergeist.” My heart sank as I looked for the next exit to turn around.

As I was walking into the hospital my phone lit up, I was getting calls left and right. As you can imagine with five surveyors, there were many people at one time looking for information. I wrote everything down and sprung into action. I have to say it was incredibly stressful as my colleagues seemed to forget everything we put into place and needed to be reminded of what they were doing. This went on for three days. In most cases, we were able to provide them with everything they needed, and even though the survey was stressful I felt good about it. At the end of each day, they provided a debriefing of what they found and the next day’s schedule. I felt like they were really digging deep to find things.

At 4 p.m. on Friday they gave us an exit report, they were very complimentary of our programs and called us a “learning organization.” We made it!  Here are some of the things they focused on.

Life safety guy:

  • Looked at every smoke door
  • Looked at the RPTs in OR
  • Looked hard for penetrations EOC
  • Looked at annual evaluation, said plans were adequate but would like them to be more robust
  • Stressed the plans should be a living document, changing as things change within the facility
  • Looked for clutter and for med gas valves being blocked or mislabeled
  • Explained importance of scope, objectives and policies for EOC
  • Also liked that all work request for equipment under OEM contract were in the CMMS
  • Said all medical equipment needs to be on an inventory for CMS, including IT equipment and facility equipment
  • Asked for three pieces of equipment, lift and Hi-Lo table

The nurse surveyor inspected the radiology department and offsite centers. She asked to see imaging records. I showed her our computer system. We went through the imaging inventory. I showed her some histories and we looked at a couple work orders together.

At the end of the day, our survey was pretty good. We did not have any immediate jeopardy items, but we still have some opportunities for improvement. For me, I was able to give my presentation via Go To Webinar, it wasn’t ideal but I think it went OK. Although I am glad to have this survey behind me, I am sorry I was not able to attend the MD Expo. Now, I am just waiting for DOH at another one of our facilities.

Jim Fedele, CBET, has been with Medical Dealer magazine for more than 12 years. He is currently the director of clinical engineering for Susquehanna Health Systems in Williamsport, Pa. He can be reached for questions and/or comments by email at