Calling the Shots: Nursing News and Notes

Preparing for Your Joint Commission Visit

Preparing for Your Joint Commission Visit

Tuesday, September 26, 2017
Preparing for Your Joint Commission Visit

If you're thinking about becoming accredited or renewing your accreditation by The Joint Commission (TJC), a site visit is an important part of the process. This might send anxiety through the halls of your facility, but it doesn't have to.

An independent, not-for-profit organization since 1951, The Joint Commission provides accreditation and certification to nearly 21,000 health care organizations and programs in the United States. The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.

Accreditation & Certification

Facilities eligible for Joint Commission accreditation include:

  • hospitals (general, children’s, psychiatric, rehabilitation, and critical access)
  • home care, including medical equipment, pharmacy, and hospice services
  • nursing care centers, such as nursing homes and rehabilitation centers
  • behavioral health care and addiction services
  • ambulatory care, for example office-based surgery practices
  • laboratory services (independent or freestanding clinical laboratories).

Knowledge about expectations and extensive preparation for the visit will facilitate a successful and rewarding visit. To prepare, use the latest manual from the Joint Commission for your particular type of healthcare facility, and allow ample time to review accreditation standards.

Joint Commission surveyors visit applicants a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. All regular Joint Commission accreditation surveys are unannounced. 

Joint Commission surveyors are highly trained and certified experts in healthcare. During the survey, they select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they observe the doctors, nurses, and other staff providing care, and often speak to the patients themselves.

Planning for a Successful Visit

To assure a successful accreditation visit, thorough preparation is essential. Suggestions for preparation include the following:

  • Establish a plan with a timeline for all preparation activities.
  • Assign responsibilities for each category of standards and all activities.
  • Become familiar with the standards.
  • Focus on the intent of each standard.
  • Identify existing examples of evidence.
  • Identify areas of partial or no compliance with standards.
  • Develop a plan to achieve compliance of identified areas.
  • Implement and evaluate the plan.
  • Incorporate standards into day-to-day work.
  • Educate all staff on the standards and ways the organization meets them.
  • Inform patients about the visit and possible questions so they will know what to expect.
  • Keep at least a year's track record of evidence.
  • Do a mock survey and score all applicable standards.
  • Read literature relevant to accreditation of setting.
  • Network with others who have gone through the accreditation process.

Preparation for accreditation requires the ability to compare and contrast. Compare the Joint Commission standards with the organization's performance. Are these similar or different? If similar, what evidence of that similarity can be made obvious to the Joint Commission visitors? If different, what can you do to become compliant?

The Payoff

The benefits of Joint Commission certification are more than just improved quality of patient care. Certification standards provide a framework for your disease management program structure.

Meeting Joint Commission standards promotes a culture of excellence across the organization. The accomplishment is recognized with the awarding of The Joint Commission’s Gold Seal of Approval®. Certified organizations proudly display the Gold Seal to advertise their commitment to health care quality.

In some markets, certification is becoming a prerequisite to eligibility for insurance reimbursement, or participation for managed care plans and contract bidding.

Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting high performance standards.

Further Resources

To help you ensure compliance, we’ve partnered with Joint Commission Resources (JCR), on a series of co-developed online courses that promote Patient Safety and Compliance, support Disease-Specific care certification in Heart Failure and Stroke, and advanced certification in Joint Replacement. 

These co-developed CE courses are part of the Lippincott Professional Development Collection competency management and validation software for institutions.  Click HERE to learn more about how these robust courses can help you increase clinical competency and stay in compliance with national guidelines!

 

 

 

 

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