What you need to know about TJC’s 2021 Survey Activity Guide


March 11, 2021

by A.J. Plunkett (aplunkett@decisionhealth.com)

After some delay, The Joint Commission’s (TJC) 2021 Survey Activity Guide (SAG) is finally online.

Be sure to check the “What’s New for 2021” section. Many of the updates, such as the elimination of the Environment of Care session, are not unexpected. Other items did not change, such as the documents that will be requested on the first day of survey.

However, be aware that TJC is “clearly trying to get more time for tracers,” notes Jennifer Cowel, RN, MHSA, CEO of Patton Healthcare Consulting and a former TJC executive and nurse surveyor.

“They eliminated the initial surveyor planning session the first morning after the opening conference.  This was normally used to review the day one documents and plan the detailed agenda,” says Cowel.

She said they have also combined two of the 30-minute sessions, Issue Resolution and Team Meeting/Surveyor Planning, into a single meeting.  That means, she says, there will be “more tracer time and less time for surveyors to plan and digest and consult with each other.”

“I would recommend that day one documents are organized, easy to access (no plastic sleeves you need to pull documents out of) and ready the very start of day one,” advises Cowel.

She suggests you also be prepared for food to be immediately available at the start of the 30-minute lunch period.  “Give them lunch and give them quiet time during this very limited lunch break. The surveyors can plan their combined 30-minute issue resolution/team meeting/surveyor planning either during the day, end of day or just after lunch. Get the team leads opinion and plans.”

Other observations from Cowel about the revisions and what it means for surveys:

  • Environment of Care (EC): The EC session has been eliminated and according to the SAG “The topics that were addressed during this session will now be covered throughout the survey by Life Safety Code® surveyors and clinical surveyors during Individual Tracer, Facility Orientation, and Building Assessment activities.” Cowel notes that “related to this, the Life Safety & Environment of Care Document List and Review Tool has been expanded to add more detail on requirements.”
  • New Survey Tools introduced: “They have included survey tools for Medical Staff System tracer, a kitchen tracer survey guide and a tracer tool to focus the review of the various imaging modalities and required document review,” notes Cowel. The kitchen tracer guide change was announced at the annual American Society for Health Care Engineering’s 2020 conference.

“These tools have been circulating in 2020 and they are welcome addition to the survey guide,” notes Cowel. “We strongly recommend that hospitals share these tools with the subject matter experts and have the required documents pulled, reviewed, updated and waiting for the surveyor when that portion of the survey occurs.”

“These are open book tests,” she continues. “You should also use these documents to do your own internal self-assessment of readiness.”

One tool eliminated is the Perinatal Survey Guide. Cowel notes that new standards are in effect this year in addition to TJC publishing a related R3 report. “I would suggest using the standards and the guidance in the R3 reports to self-assess compliance with these new important standards.”

The SAG notes the tool has “been removed from the guide for editing and refinement for health care organizations.”


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