03/14/2017

Joint Commission ASC Survey Changes for 2017

10 Things to Know -- Published by AORN

Here are 10 things to know about The Joint Commission's ASC survey changes.

1. Only affects Medicare-deemed ASCs. If your ASC does not use the Medicare-deemed option for your Joint Commission survey, the changes will not apply to you. "This change was made to put us in compliance with instructions from the Centers for Medicare & Medicaid Services (CMS)," says Michael Kulczycki, MBA, executive director for The Joint Commission's Ambulatory Care Accreditation Program.
   
   
2. Does not apply to all Medicare-deemed ASCs. Medicare-deemed ASCs with low patient volume will not experience a change to the typical one-surveyor, two-day Joint Commission survey event. "About one-third of our ASCs will not see any changes," Kulczycki says.
   
   
3. Affected ASCs will see one of two changes. If an ASC has larger patient volume, it can expect one or two changes to the survey experience.
   
   "In some cases, the survey will now be a single surveyor for a three-day event," Kulczycki says. "In other cases, it would go to two surveyors for a two-day event. The type of change depends on the ASC's volume."
   
   
4. No change to the Life Safety Code component. The Life Safety Code component of the survey is not affected by these changes. It will remain a one-day addition of one Life Safety Code specialist surveyor, barring extenuating circumstances that require additional time.
   
   "The changes only impact the clinical components of the Medicare deemed status survey," says Pearl Darling, MBA, associate director for The Joint Commission's Ambulatory Care Accreditation Program.
   
   
5. No change for de novo ASCs. New ASCs will experience the "traditional" survey experience of a single surveyor for two days plus the Life Safety Code specialist surveyor for one day.
   
   
6. Opportunities for expanded education. The revised survey process should provide ASCs with more opportunities for education and improvement, Darling says. "We hear a lot of feedback from organizations that the survey experience itself is very meaningful and educational. For ASCs that will now be visited by two clinical surveyors, they will receive twice the insight. For ASCs that gain an extra day, that's one more day of feedback."
7. Improved consistency. Kulczycki says one of the top requests from survey participants is consistency in standards interpretation. "That's consistency from surveyor to surveyor, one survey event to the next and when they call for Joint Commission for expertise."
   
   Two clinical surveyors onsite together should help with that consistency, he says. "They have the ability, in private, to bounce their observations off each other. If there's an issue of noncompliance, they can work to make sure it is scored correctly the first time as opposed to a report coming into The Joint Commission requiring a later fix."
   
   
8. Reduced footprint. Very busy ASCs are welcoming the reduction in number of days surveyors are onsite, Kulczycki says.
   
   "We heard from the administrator of one ASC whose old survey method was one surveyor for three days," he says. "The new method for the ASC, given its volume, is two surveyors for two days. The administrator prefers this because our footprint affecting that organization is smaller because the survey time is shorter. Just as important to this administrator is that the change in survey experience does not reduce the value of the survey to providing quality patient care."
   
   
9. Fees will adjust. Survey fees for Medicare-deemed ASCs will be adjusted, if necessary, to reflect the changing number of surveyors and length of the survey.
   
   
10. Across-the-board CMS mandate. The CMS guidance for survey changes does not just apply to The Joint Commission, Kulczycki says. "CMS has committed to us that they expect the same guidance to be adhered to by the other accreditation organizations that survey on their behalf. If these organizations have not made these changes yet, that may be happening in the future."

Note: If you are interested in learning more, check out The Joint Commission's "Take 5" podcast focused specifically on the 2017 changes for deemed ASCs.