the Joint Commission's on-site survey: Be prepared

March 29, 2015

The Joint Commission’s in-person surveys of hospital pharmacies are rigorous, said a hospital executive at the APhA annual meeting in San Diego, and preparation should be just as exacting.

The Joint Commission’s in-person surveys of hospital pharmacies are rigorous, a hospital executive told an audience at the annual meeting of the American Pharmacists Association in San Diego, Calif., and preparation should be just as exacting. 

“We have to be survey-ready at all times,” said Melinda Joyce, PharmD, FAPhA, FACHE, vice president of corporate support services at Commonwealth Health Corporation in Bowling Green, Ky. “Clean and declutter. Educate: Talk to your staff like a surveyor. Ask them questions. Read and read and read those standards.”

According to Joyce, hospitals across the country wait anxiously each morning for word from the Joint Commission’s website about which ones will face in-person surveys. When hospitals are chosen, she said, they’ll face a different experience than in the past.

First impressions count

“The process has changed pretty substantially,” Joyce said. “Now the Joint Commission is the eyes and ears of the Centers for Medicare & Medicaid Services in order for hospitals to have deemed status.” This allows hospitals to participate in the Medicare and Medicaid programs.

It’s crucial to be ready on an ongoing basis because hospitals will have only a few minutes to prepare for the sudden surveys, Joyce said. “First impressions are huge. Eliminate clutter. Make sure hallways, pantry areas, and breakrooms are clear.”

Among many other things, Joint Commission surveyors look for signs that hospital pharmacies are protecting patient information, dating and authenticating orders, and removing expired items, Joyce said.

Nursing staff will face questions of their own to make sure they understand procedures. “If the surveyor asks, ‘What is a hazardous medication?’ and they get that deer-in-the-headlights look, that’s not going to work,” Joyce said.

According to Joyce, Joint Commission surveyors will explore a wide range of pharmacy issues that also include safety and labeling procedures, procedures involving sound-alike and non-formulary medications, and much more.

Surveyors spotted problems involving equipment and devices alone in half of hospitals in 2014, she said, such as CaviWipes containers that were not closed and bottom wire shelves that lacked impermeable covering.

“The goal is an outstanding survey,” Joyce said. “More importantly, following the standards helps you to provide outstanding quality patient care.”