Are You Prepared for the Joint Commission Survey?
Accreditation is recognition of a commitment to excellence, and the mission of the Joint Commission (JC) is to consistently improve health care, inspiring hospitals and other organizations to excel in safe and effective care. Join the survey process as a partner stretching to reach the highest professional standards.
When has passing the test been enough? Being prepared is a way of life and work, and excellence doesn’t come from accreditation or approval but in the ongoing days, weeks, and years of preparation, practice, and learning. It’s not a question of getting ready for the survey and then relaxing until the next time. The whole point of the exercise is to uphold quality and safety standards. Nevertheless, you do study for a test, and you do get ready for the unannounced Joint Commission survey.
What is the Joint Commission?
JC sets healthcare quality and safety standards, evaluates healthcare organizations, and provides both participatory training options and highly-respected certifications that can be required for licensing and payments from both Medicaid and Medicare.
FAQs about the Joint Commission
Is JC accreditation mandatory?
Accreditation is mandatory, but there are several accrediting organizations to choose from. Howbeit, the Joint Commission is the most widely accepted of these organizations.
Who interprets the over 250 hospital accreditation standards?
Contact the Standards Interpretation Group to help you interpret the standards for your hospital.
What are the benefits of JC certification?
Please read the Nursa article that clearly states some important advantages.
For more FAQs, see JC FAQs and Benefits of JC Certification.
How Should I Prepare? Seven Essential Tips
1. Study the Manual
JC works on improving the standards of healthcare and publishes the changes in its Survey Activity Guide. Between JC surveys, it is crucial for your organization to promptly review the latest version, staying informed of any changes relevant to your type of facility, to preempt any potential issues during your survey.
2. Get Everyone On Board
Make sure everyone in your organization, from staff to executive leaders, is well-informed and identifies with the process and the goals. Is everyone updated on standards relevant to their positions? Does each person know what they should be doing during the event? Keep people focused and involved in consistent quality care through systematic safety moments, posters, cards, or attractive meetings and clear communication.
- Consult in internal meetings to assess your organization’s compliance with the standards.
- Safety Moments are 5-minute safety messages used to reinforce safety culture and draw attention to potential hazards, usually delivered at the beginning of a meeting or shift and presented in a variety of creative ways. They are most effective when all staff members take turns presenting Safety Moments.
- To strengthen awareness, distribute cards with key points regarding quality and safety standards, and encourage discussions around them. Managers can make a game of asking individuals if they remember their point. Additionally, share engaging memes in organizational messaging groups like WhatsApp to reinforce consequential points.
3. Establish Communication Plans
Clear communication, always crucial to reliable healthcare, helps you stay organized and move along efficiently during a JC survey. Build your survey-specific communication plan well in advance, perhaps including notification templates, such as “TJC surveyors are here!”, a prompt for the hospital survey team. Run drills, so staff immediately recognize the messages and know how to respond, bearing in mind that rapid notifications can rally everyone together, taking full advantage of the brief preparation window.
4. Go Over Notes from Previous Surveys
Study your past survey performance, and make sure you have diligently kept up with all the required improvements you have painstakingly achieved. Remember to double-check on any changes in standards since then to ensure current compliance.
5. Check Documentation
A large part of the survey will be spent on vital, but not so exciting, record management. To help you have the records updated and at your fingertips, keep a documentation checklist and review it periodically.
Please see the complete list of required documentation in the manual, however here are a few examples of what you should have ready:
- Hospital license,
- CLIA certificates,
- Organizational chart,
- Data from your latest culture of safety and quality assessment,
- Certain lists include:
- All sites eligible for the survey,
- High-level disinfection and sterilization sites,
- Departments/units/areas/programs/services within the organization,
- Patients with: name, location, age, diagnosis, length of stay, admit date, source of admission (ED, direct admit, transfer),
- scheduled surgeries and special procedures,
- Performance improvement data from the last 12 months,
- Patient flow documentation,
- An environment of Care data,
- Emergency management documentation,
- And much more.
The first information you will provide to the surveyors is the list of staff members who will escort and assist them in the survey.
6. Appoint Survey Teams for Each Shift
As the survey time approaches, you will not know exactly when it will begin, so create survey teams for the various shifts. Select friendly, helpful staff members who know the organization well to provide optimal support to the surveyors.
7. Conduct a Mock Survey
Conducting a trial run familiarizes both new and experienced staff with the potentially intimidating survey process. With a full-scale drill or even a classroom simulation, the actual survey day can go far more smoothly.
Joint Commission Resources
The Joint Commission wants this to work well and provides a wealth of complimentary resources, such as a JC Account Executive assigned to you to answer questions, a Snapshot of Survey Day, a Readiness Roadmap Toolkit, many other tools, and hundreds of webinars and training materials. Take advantage of these online resources to maintain hard-won progress and prepare for hospital inspection.
Shared Aspirations and Goals
You and the Joint Commission are in this together, striving for the very same goals of ever-higher standards of healthcare quality and safety, raising the bar of healthcare excellence.