Virtually every standard or element of performance The Joint Commission (TJC) publishes is capable of being evaluated and scored from a compliance standpoint. This creates opportunities for improvement through corrective actions or program changes. Most of the activities we do in the Physical Environment are designed for the purpose of identifying problems. Whether we are testing systems and equipment, conducting Environment of Care meetings, doing Risk Assessments, Environmental Tours, or evaluating fire drills, everything is designed to allow us the opportunity to capture data that will help us identify where our problems are and what opportunities we have to improve those parts of our programs and organization. With almost every task we do, we are testing either our staff knowledge, our staff performance, or the performance of the equipment and systems they use. As we document these knowledge and performance outcomes, we are automatically collecting data on the extent and quality of staff knowledge, staff performance, or equipment/system performance. Failure to use the information we have gathered from these tests and activities as well as failure to make corrections and improvements to our programs as a result of the information we have gathered may be one of our greatest organizational failures and may cause substantial damage during an Accreditation survey.
At almost every TJC survey, somewhere during their process of reviewing documentation, the surveyor will identify numerous if not dozens of occasions where these records of the organization, or those provided by their vendors, clearly indicate that there was a problem, shortcoming, or failure. In way too many cases, the organization is unable to provide the surveyor clear evidence to demonstrate that corrective actions have been taken.
Once we have captured this information, TJC expects that in every case, we evaluate the seriousness of the issue, establish a plan of correction for the item, and monitor it through completion.
Information regarding deficiencies in the Physical Environment can come from a great many sources including activities and reports from things like vendor inspections, preventive maintenance programs, emergency drills, environmental tours, risk assessments and many other areas.
Perhaps the simplest, clearest, and most user friendly way to track this data is to have one deficiency tracking report for all identified deficiencies in an excel type format which can be sorted by deficiency type, department, source report, length of correction, etc.
The attached form demonstrates one way that deficiencies can be tracked to completion and at the same time provide organizations with meaningful data regarding completion levels and timeframes. The Joint Commission does not specifically require that organizations track specific data in this specific manner. However, having a clear program for tracking and resolving issues and deficiencies has proven an effective method in past surveys in improving the surveyors comfort level with the organization and helping improve their accreditation survey outcome. This form might for example be used as a report and handout at each Safety Committee meeting to make sure members know and the organization is confident that we have a process for tracking correction of problems.
