Preparing for Joint Commission Surveys

Clinical Corner

By Brian Gallagher

The overhead page repeats three times: “Gotham City Hospital would like to welcome the Joint Commission.”  It’s the one page that can strike panic into even the most prepared organization. Team members run through the department making sure there is no food or drink visible. Cabinet doors and drawers are locked, wipe containers are closed, policy binders are easily available. Name badges are checked to make sure they are on their lapel and not on the waist.

One day, the Joint Commission will set foot on your hallowed ground – so here are a few ways to make sure you are comfortable and prepared for the upcoming surveys. 

The Joint Commission: An Overview

The Joint Commission (TJC) is an independent, not-for-profit organization that “accredits” more than twenty-two thousand healthcare organizations and healthcare programs in the United States. Joint Commission accreditation is a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Therefore, accreditation is highly sought and – once achieved – highly prized. 

Joint Commission surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other healthcare professionals. They visit accredited healthcare organizations a minimum of once every 36 months (two years for laboratories) to evaluate compliance. This visit is called a survey. All regular Joint Commission accreditation surveys are unannounced. 

Joint Commission standards focus on patient safety and quality of care.  These 250+ standards are updated regularly to reflect the rapid advances in healthcare and medicine. They address everything from patient rights and education, infection control, and medication management to the prevention of medical errors, staff verification, and emergency preparation. They also examine how the facility collects data on its performance and uses that data to improve itself.

During the survey, surveyors select random patients and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in the organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe care delivery and often speak to the patients themselves.

But accreditation does not begin and end with the on-site survey. It’s a continuous process. Every time a nurse or provider double-checks two patient identifiers before administering medications or care, calls a “time out” to verify they are about to perform the correct procedure, at the correct site, on the correct patient, these clinicians live and breathe the accreditation process. 

Every three months, hospitals also submit data to the Joint Commission on how they treat conditions such as heart attack care and pneumonia. Throughout the accreditation cycle, organizations are provided with a self-assessment scoring tool to help monitor their ongoing standards compliance.  TJC accreditation is woven into the fabric of healthcare operations.

Success Starts with Preparation

Surveys are typically a stressful timeframe for an organization – but preparation helps.  This is your chance to show off your team’s hard work and dedication. Remember, you are the expert for your department, not the surveyor. To ensure you’re ready, you’ll want to do the following:

  • Keep documents and employee files up to date.
  • Ensure processes, policies, and procedures are current and being followed.
  • Ensure all outstanding items are resolved in a timely manner. 
  • Perform mock surveys.
  • Inspect departments and verify team members understand policies and procedures. 
  • Review typical Joint Commission questions and come up with good answers.

How to Speak to Surveyors

Surveyors are people, just like you. We all have a job to do, and theirs is to ensure you are following the rules and regulations set up to provide the safest environment and best care possible.

Speaking to surveyors can be nerve-wracking, but the following tips can help: 

  • Be courteous and respectful. Maintain eye contact throughout your interactions.
  • The surveyors will observe you while you are performing direct patient care.
    • Make sure you introduce yourself to the patient with your name and title.  Confirm two patient identifiers. “Good morning, Miss Quinn. My name is Dr. Wayne and I am a physician who’s here to help you. Can you please tell me your full name and date of birth?”
  • Keep your communication concise and positive.  Only answer the question you are asked.
    • Take time to consider what the surveyor is looking for.  Ask the surveyor to repeat or clarify if you don’t understand.
    • Expect standard-related questions involving patient safety, environmental safety, staffing quantity and competency, performance improvement, patient rights and infection control.
    • Watch your use of words such as “usually” or “supposed to” or “sometimes.” These can lead surveyors to ask why you don’t consistently follow your procedures.
  • Answer questions truthfully in clear, simple terms based on your everyday practice. 
  • If you are unsure or don’t know the answer, respond with, “Let me find that answer for you.”
    • Don’t be afraid to use your resources.  You are allowed to read directly from your hospital policies and procedures. 
    • Contact your supervisor if necessary, then get the correct answer to the surveyor.
    • The surveyors only want the correct answer. Don’t make it up if you don’t know.

Above all, carry yourself with confidence. Show the pride you have in your facility and department. This is a great opportunity to share the diligent effort and incredible work your team does every day!  Just do your homework and preparation, and you’ll be on your way to a successful Joint Commission survey.

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