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Decide in advance who should be notified
When the Joint Commission comes knocking, you have to be able to respond quickly. It is to your advantage to have all the right hospital leaders and consultants on hand to assist, so you must plan now for a system that gets all those players in place with little notice.
You should decide ahead of time who you need to be involved in an unannounced Joint Com mission visit and devise a system for rallying them, suggests Peggy Nakamura, RN, MBA, JD, DFASHRM, executive director of risk management and associate counsel at Adventist Health in Roseville, CA. She also is immediate past president of the American Society for Healthcare Risk Management in Chicago.
The first step, she says, is to determine who needs to be notified and/or present as the Joint Commission pokes around your hospital.
The first person who should be notified is yourself. The risk manager must be told as soon as possible when anyone — anyone — at the hospital gets word that the Joint Commission is on grounds or on the way. The receptionist, the security guard, the chief executive officer’s secretary — anyone who might first encounter Joint Commission representatives or receive their calls — should know that this is a high-priority event and that the risk management department should be notified immediately. Nakamura recommends classifying this right up there with major adverse events that require quick notification of the risk manager.
A paging system may be desirable
Depending on your exact circumstances, you might even want to institute a paging system that alerts all the key players with a special code on their pagers, for instance. In most cases, however, it probably is sufficient to use a phone tree in which the first person to hear of the visit calls the risk manager, who then is responsible for calling everyone else who is needed.
Nakamura suggests including the chief executive officer, the director of medical records, the director of quality management or quality improvement, and possibly the compliance officer. Others within your own organization might be appropriate. In addition, Nakamura strongly urges you to contact legal counsel the minute you hear of the Joint Commission’s visit.
If you have in-house legal counsel, that person should be included on the response team. But even if you use outside counsel, Nakamura says it would be money well spent to have that person present. It will be necessary to explain ahead of time about the possibility of a surprise Joint Commission visit and why such a visit would require the attorney to drop everything and get to the hospital immediately. Don’t be surprised if the attorney says that could be difficult; you still need to press for an immediate response if at all possible.
"I think we’ll have to treat it almost like an emergency," Nakamura says. "You don’t have any time to waste before people start handing over things they shouldn’t or before the Joint Commission starts to think you’re just trying to cover up something. Get your folks in there and get some good decisions on what you can turn over."