THE JOINT COMMISSION - TRIENNIAL ACCREDITATION SURVEY

Summary The Joint Commission (TJC) conducted UTMB’s unannounced triennial accreditation survey May 16th through May 20th, 2022, covering all 6 hospitals and more than 60 clinics. The surveyors reviewed over 10,000 pages of compliance documentation, all hospital areas and many of the clinics. This was the largest, most comprehensive survey UTMB has experienced since it included all 4 campuses for the first time. Surveyors were thorough and cited every deficiency they saw. UTMB’s diligent teams managed to reduce our number of findings in Environment of Care (EOC) and Life Safety (LS) by about 30% from the last triennial survey! There were no significant findings that would result in a conditional status. This was accomplished despite the challenges of the COVID pandemic and weather events that forced us to create new ways to conduct critical business.

Strategic Preparation Efforts EHS specifically coordinated some efforts to always be ready and prepare for TJC audits. Some of these activities included: • EHS working directly with and hosting third-party audits of our programs, mostly virtual. Performed with Property Services, EHS hosted, tracked, and resolved findings reported. • EHS, along with Design & Construction and Property Services developed a strike team to survey facilities and correct deficiencies found on-the-spot, as much as possible. Of 2,352 findings, 2,058 were corrected prior to survey (88%). This effort helped to significantly reduce the number of TJC findings from previous surveys. • EHS developed a significant, comprehensive, and smart digital library of compliance records.

Designed to match TJC standards, the system made it easy to help navigate the surveyor through well over 10,000 pages of records. This set a positive tone with the surveyors, which lasted throughout the survey.

This library has become a truly integrated effort across departments, including all of EHS, Property Services,

Utilities, and Clinical Equipment groups. • EHS developed a physical and electronic/virtual command center for the survey. Through use of

Microsoft Teams (Teams) and other electronic applications, we hosted the survey with a minimal amount of people while having a large resource pool available electronically. Questions from each subject matter expert were typically answered on the spot and scribing information/action items through Microsoft

SharePoint (SharePoint) were immediately available for others to immediately correct. • Drilling for the survey. All the above tactics were pre-tested to ensure they would be effective prior to use.

Executing the Survey The LS survey was conducted out of a conference room with Teams running in the background. Field scribes were dedicated to the survey as usual, however this accompanying team utilized SharePoint to keep notes “live” for other team members to monitor and act on in the background. The Teams application was utilized to track the survey’s progress, react quickly to concerns and answer all questions raised by the surveyor that couldn’t be answered by an escort. In short, while the survey was grueling, all of the preparation efforts paid off handsomely.

More than just planning for and executing a well-run survey, EHS holds firm beliefs that we have a key role in keeping our patients, visitors, and employees safe in our facilities. This is our passion executed in the most effective way we know how.