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Announced Intracycle Monitoring Survey Helps Prepare Staff for the Real Thing

Yakima Valley Farm Workers Clinic recently completed an Announced Intracycle Monitoring Survey conducted by the Joint Commission. The Joint Commission is responsible for setting standards, providing accreditation to health care […]

Intracycle Monitoring

Yakima Valley Farm Workers Clinic recently completed an Announced Intracycle Monitoring Survey conducted by the Joint Commission. The Joint Commission is responsible for setting standards, providing accreditation to health care facilities, and conducts unannounced monitoring surveys every three-years and ensure standards are being met. The announced survey is an in person, non-punitive, tool organizations can use to help prepare for the unannounced surveys. The organization requesting the survey can choose what facilities and services they want looked at. They can also ask survey teams to look at areas where findings were previously issued to ensure they have been adequately corrected.

The Quality Department at Yakima Valley Farm Workers Clinic is responsible for managing the surveys. For the recent survey they chose to focus on dental because new standards were introduced this year. The announced survey mirrors the unannounced one and looks at a wide range of health care standards, from specifics about patient care to sterilization of instruments and hazardous waste procedures.

“There is no shortage of things you have to know,” said Lori Kelley, Vice President of Quality & Compliance at Yakima Valley Farm Workers Clinic. “We bring them here to help us look at processes that we think we could be at risk for in a real survey.”

If there is any disagreement between a surveyor and an organization about how a rule should be interpreted, the organization can ask to have it reviewed by the Standards Interpretation Group (SIG) at the Joint Commission. This was utilized when an issue came up regarding a finding from an earlier inspection. The original finding was for not asking enough questions about a person’s pain level during a behavioral health interview. The issue was corrected, but during the announced survey, a new inspector felt we were now asking too many questions.  Kelley asked SIG to provide a resolution and clearer guidance.

“SIG came back and said you need two questions,” said Kelley. “We said great, we’ll institute that change.”

If a finding is made during the announced survey, as long as it is not something serious, there is no report generated, and the organization can correct the problem before the unannounced survey.  The Quality Department also informs all other Yakima Valley Farm Workers Clinics about what was found, so they can take similar action if necessary.

While it costs money to have an announced inspection done, and some people consider it to be an unnecessary, stress inducing exercise, Kelley feels it’s worth it.

“I really believe that both the unannounced and the announced surveys are good investments,” said Kelley. “Every organization should bring in somebody from the outside to look at them and their practices and make sure that their practices are best practices and on par with evidence-based health care.”

Beyond the announced survey, the Quality Department does a number of things to help prepare staff for the unannounced survey. One is the distribution of a newsletter which provides an in-depth look at a different health care standard each week.

“It reviews one standard, what the standard means, how often organizations are cited for it, what this means to our front-line employees, what it means for leadership in our organization, what we don’t want you to do when a surveyor’s here, and then some FAQs on that particular standard,” said Kelley.

In addition, the Quality Department also performs their own, unannounced surveys.

“We go out and do mock surveys where we show up at your front desk, and instead of being Lori Kelley we say, “Hi we are here to do your Joint Commission Survey,”” said Kelley. “We try to really ask the staff the same questions that Joint Commission surveyors ask, look at the same areas, and seek out those areas that we can improve upon before we get a true survey.”

The Quality Department takes the surveys seriously because health care facilities can be closed for poor performance. While a major finding, such as an immediate threat to the life of a patient, can lead to closure of a facility, minor findings can add up and have a significant impact on an organization.

“There are no monetary fines, but it does affect the type of accreditation you get,” said Kelley. “It’s a quality grade. So, you might be average, you might be a gold star, you might be a silver star, or you might be closed.”

Obviously, there is a lot riding on the results of the unannounced survey, and the Quality Department is using every tool it can to ensure the staff of Yakima Valley Farm Workers Clinic are ready for it. The results of the recent survey show the department’s work is paying off. According to Kelley, the survey went well, and the surveyors had some very good things to say about Yakima Valley Farm Workers Clinic:

  • The Behavioral Health Services team has made a tremendous amount of progress since our last survey; the changes are impressive and show your dedication to patients.
  • Clinical locations are beautiful and staffed with talented, compassionate individuals.
  • Processes and procedures are ahead of the industry.
  • Yakima Valley Farm Workers Clinic’s dedication to good outcomes is commendable.
  • The risk assessment performed by the team are some of the best we have seen.

The next unannounced survey will take place sometime in the first half of 2024, and the Quality Department will continue to work to ensure Yakima Valley Farm Workers Clinic staff are ready for it.