Calling the Shots: Nursing News and Notes

‘They’re Here!’ The Visitors Who Incite Angst and Why Hospitals Pay Them Thousands of Dollars to Stop By

‘They’re Here!’ The Visitors Who Incite Angst and Why Hospitals Pay Them Thousands of Dollars to Stop By

Tuesday, January 20, 2015
A look at Joint Commission onsite surveys and the stress felt among healthcare professionals.

“I came to work today only to find nurses and administrators in a state of subdued panic,” writes an emergency department physician from South Carolina. “I wondered why everyone looked like they had just seen werewolves.”

“I descended into the depths of hell last week rather than the well organized, pleasant ICU I have grown accustomed to working in over the last few months,” responded a nurse. “I find my charge nurse sprinting from room to room with a light sheen of sweat on her brow as she checks the expiration dates on the bottoms of alcohol hand sanitizer found in each doorway… As I approach New Grad, she slowly raises her eyes to mine as would a beaten puppy and whispers in a tone one could only imagine hearing from a war veteran in a PTSD-induced panic attack, ‘I couldn’t tell them the difference between the FLACC, BPS, and Wong-Baker pain scales.’”

“Sheer terror, desperation, and panic,” observes another nurse.

What prompted the chaos witnessed by the clinicians?

In all three cases, it was a visit from The Joint Commission.

Why Joint Commission Accreditation Matters

Perhaps a bit exaggerated (although, without a doubt, entertaining reading), the anecdotes offer a glimpse into the power of a voluntary accrediting agency that hospitals have hired to give them the thumbs-up or thumbs-down since its establishment in 1951.

Hospitals and healthcare programs that comply with hundreds of voluntary Joint Commission performance standards earn its gold seal of approval and subsequent benefits, which can include:

  • meeting state regulations
  • participating in Medicare and, in some states, Medicaid programs
  • higher insurance reimbursement due to higher standards of care

The cost of Joint Commission accreditation ranges between $1,780 to $36,845, depending on a hospital’s size and complexity of care it offers.

What an Onsite Survey Involves

More than 20,500 hospitals and healthcare programs currently carry Joint Commission accreditation, which they earn after an intensive, on-site review. To maintain Joint Commission accreditation, hospitals undergo an additional inspection by on-site surveyors at least every 3 years.

Once upon a time, hospitals received notice of when a survey would occur. Not so since 2006, when the commission changed its policy to unannounced inspections that occur sometime between 18 and 39 months after a hospital’s last inspection.

During an onsite inspection, Joint Commission surveyors—physicians, nurses, and other healthcare professionals—observe hospital units, interview staff and patients, and review procedures and even medical records for compliance with more than 250 standards. Standards are comprehensive and address:

  • infection control
  • medication management
  • medical error prevention
  • clinician competence
  • emergency preparedness
  • patient rights and education  
  • data collection and performance improvement

Until Next Time…

Hospitals are notified of survey findings a short time afterwards. If a hospital fails to comply with a performance standard, it is required to submit a plan of action outlining how it will improve its performance.

 In addition, accredited hospitals submit data quarterly on how they treat conditions including heart attack and pneumonia. Annually, they must also evaluate their ongoing compliance to standards through periodic performance reviews.

Many hospitals also conduct mock survey drills to practice for future Joint Commission visits. As the powerful accrediting body states on its website, “Joint Commission accreditation is woven into the fabric of a health care organization’s operations.”

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