TJC Survey

The Joint Commission Survey can be a stressful time for hospitals. The ultimate goal of course is to maintain compliance and readiness in all areas, so any time a surveyor walks into your facility, you are ready. From the pharmacy’s perspective, this is comparatively easier to do if you have an engaged team. However, when it comes to medication management outside the pharmacy, it’s harder to ensure complete compliance. A common finding is in the area of IV drips – did the nurse follow the order when it comes to titration and documentation of all necessary vitals and scores? 

Other trends I am seeing on this go round in California is a solid interest in Antibiotic Stewardship. Surveyors will want to hear all about your program. They seem to also want to hear about your glycemic program. Directly within the pharmacy, they have taken a more detailed interest in the sterile compounding room. When my hospital was surveyed, the surveyor gave me a TJC Surveyor Guidance Checklist for On Site Activity the day prior so I could be prepared. The checklist included the assessment item, guidance on compliance, and the Joint Commission Standard regulation number. It gave me time to prepare, and in my preparation I realized I needed an inservice on how to read TSS reports. It really should not be that complicated! The Facilities Director ended up being invaluable to me on that survey day, and he saved the day with the surveyor. A reminder, all surfaces of the hood (ISO Class 5 PEC) need to be cleaned (disinfected) at the beginning of each shift, at least every 30 minutes when compounding or before each lot, after each spill, and when surface contamination is suspected. 

“Preparation doesn’t assure victory, it assures confidence.”
Amit Kalantri, Wealth of Words

Terri Vidals
Terri Vidals

Terri has been a pharmacist for over 30 years and is a drug diversion mitigation and monitoring subject matter expert. Her years of experience in various roles within hospital pharmacy have given her real-world insight into risk, compliance, and regulatory requirements, as well as best practices for medication and patient safety.

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