Joint Commission Tips

The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) is a multidisciplinary not-for-profit agency that has been accrediting organizations for more than 50 years. The organization defines its mission as working to "improve the safety and quality of care provided to the public through the provision of health-care accreditation and related services that support performance improvement in health-care organizations."

Survey Readiness

• The Joint Commission has accredited more than 16,000 heath care organizations. The agency performs unannounced site surveys of accredited organizations and for those that wish to become accredited. The survey process can take anywhere from two to four days depending on the organization's size. The fact that it is unannounced provides the surveyors with a chance to witness the true processes of the heath care organization, instead of seeing "rehearsed" actions.

The Importance of Leadership

• Part of the Joint Commission's requirements is that the organization has a strong leadership base that is actively involved in accreditation compliance. The leadership "team" as it is sometimes called, is comprised of medical-department chiefs, vice presidents, the CEO of the organization and department directors.

  Each leader is assigned one or more of the following chapters from the Joint Commission manual: Environment of Care, Emergency Management, Human Resources, Infection Prevention and Control, Information Management, Leadership, Life Safety, Medication Management , Medical Staff, National Patient Safety Goals, Nursing, Provision of Care, Treatment, and Services, Performance Improvement, Record of Care, Treatment, and Services, Rights and Responsibilities of the Individual, Transplant Safety and Waived Testing.

  Every chapter has its own specific set of requirements. The chapter leaders are responsible for ensuring compliance with all of the standards set forth in the chapters. They should develop teams for each chapter and utilize a grid outlining accreditation requirements, who is responsible, due dates, measures taken to resolve issues and plans of action. Teams should meet at least monthly and perhaps more frequently if needed. The success or failure of any organization is reflective of its leadership base.

Getting Staff Involved

• When the Joint Commission makes an unannounced survey visit, part of it survey is making rounds on unit floors and departments to observe staff members and how they work. For example, to monitor compliance with the Joint Commission National Patient Safety Goal that deals with hand hygiene, the surveyor will observe staff to see if they are washing their hands or using alcohol foam when entering and exiting a patient's room.

  Therefore, it should be an essential part of Joint Commission survey readiness to do weekly or monthly rounds. It may help to form a team of staff that will do the rounds. A checklist of the requirements should be used as a tool when performing workplace observations.

  In addition to observation, those making inspection rounds should engage other staff members by asking them a predetermined set of questions, such as: "What is the protocol for washing hands when a patient has an infectious disease?" Each staff member should be able to speak about the process. It doesn't have to be recited perfectly, just show their knowledge on the requirement.

  Engaging staff in this way can help prepare them for the real surveyors. Sometimes staff feel intimidated and scared, knowing that so much relies on their knowledge, if approached.

  It is important to remember that staff don't need to memorize the Joint Commission manual. The most important thing surveyors look for is that the staff is aware of how to contact the Joint Commission if a safety issue arises, and that they also know where to find information on the Joint Commission requirements if they need it.

  As an example, in addition to NPSG rounds, a team may be formed to do environmental-safety rounds. This team would go around making sure all requirements are met, such as not blocking an exits and keeping supplies of any kind away from sprinkler systems. A real surveyor may ask a staff member how he would get the material safety data sheet for a particular chemical. Staff members needn't know the phone number by heart, but if they can at least state something along the lines of, "The contact information is on our organization's website," that would suffice.

  Another way to prep staff for a survey would be to hold a Joint Commission "fair." Each leadership team member should make a presentation on its respective chapters. Entice staff to attend by having drawings for prizes, but make it so they are only eligible for the drawings if they visit each booth/presentation. Give them a "ticket" to take around to each one to get stamped.

  It is also a good idea to hold quarterly (or less frequent) mock surveys. During the mock survey, all events that would normally take place when surveyors arrive would be put into action. The leadership team would select three or four "surveyors" who will act as though they are from the Joint Commission. Clearly outline the expectations for each survey. Have a meeting at the end to go over results, formulate plans of action, assign responsible people and give a due date for completion.