How to Comply With JCAHO Requirements

The Joint Commission (formerly JCAHO) accredits and certifies various types of health care organizations around the country. It emphasizes high-quality patient care and makes patient safety its highest priority. To earn the Joint Commission's "Gold Seal of Approval," health care organizations must demonstrate compliance with hundreds of Joint Commission standards. These standards are broken down into "chapters" that group the requirements by patient care areas. For example, there are specific chapters for medication management, medical information, patient rights and human resources.

Things You'll Need

• Appropriate Joint Commission manual for your type of health care organization

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Instructions

• 1

  Determine how you will assess compliance for each standard (i.e., what method of data collection you will use). This requires you to determine (if the Joint Commission does not provide it) a numerator and denominator for data collection. For example, if you are measuring hand hygiene compliance in a particular unit, you would track the total number of staff members you observe, and track the number of staff members who comply with hand hygiene guidelines. The numerator would be the total number of staff members complying and the denominator would be total number of staff members observed.

• 2

  Assign a team leader to each chapter of the manual. Task them with developing a specific team whose responsibility will be educating the staff on their standards, assessing compliance, developing action plans and reporting to Joint Commission team leaders.

• 3

  Quickly identify areas needing improvement, develop action plans, provide education if needed, assign responsible persons and assign a due date for completion. Track all actions and progress, in case the Joint Commission should request this upon its arrival for its unannounced compliance survey.