By Tara Gibson - October 22, 2019
The Joint Commission 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 and therefore accreditation is highly sought and - once achieved - highly prized.
Because Joint Commission Accreditation Surveys are rarely announced in advance, accredited healthcare organizations and those pursuing accreditation need to be permanently prepared for a surprise visit. In this blog, we share five tips to help healthcare organizations pass accreditation surveys.
Healthcare organizations that achieve Joint Commission accreditation meet or surpass CMS’ standards for acceptance into the Medicare and Medicaid programs. So, although Joint Commission accreditation is not mandatory, many healthcare organizations apply for accreditation in order to prove they meet the standards required to receive payments from the federally funded programs.
Healthcare organizations that apply to be accredited by the Joint Commission are inspected by trained and certified “surveyors” who are usually highly experienced doctors, nurses, hospital administrators, or other healthcare professionals depending on the services being provided by the healthcare organization. For example, if a laboratory has applied for Joint Commission accreditation, the inspection is carried out by a certified and experienced laboratory medical technologist.
During the inspection (or “survey”), surveyors randomly select patients’ medical records and use them as a roadmap to assess compliance with Joint Commission standards. The surveyors (there may be more than one per inspection) trace the patients’ experiences through their medical journeys by talking with staff who have interacted with the patients and the patients themselves. The environments in which the patients are cared for are also inspected to ensure compliance with relevant standards.
Once accreditation has been achieved, healthcare organizations have to self-monitor compliance with the Joint Commission’s standards and submit data every three months relating to issues such as how they treat conditions such as heart attacks and pneumonia. Repeat surveys take place at 18-36 month intervals, but healthcare organizations are not warned in advance when they will take place - hence the importance of always being prepared for a successful Joint Commission accreditation survey.
Because healthcare organizations never know in advance when a Joint Commission accreditation survey will take place, the only way to prepare for an inspection is to maintain the Joint Commission’s standards all year though. However, this is not just a case of “keep doing what you are doing” and preventing bad habits from slipping in. The Joint Commission’s standards change each year as the organization strives to improve the standard of healthcare across the country.
The changes are published each year in the “Survey Activity Guide for Healthcare Organizations” under the “What’s New” section. Also included in the Guide are details of the inspection process (which vary according to the services provided by the healthcare organization), the documents each organization should have ready to demonstrate compliance to an inspector, and a checklist relating to health and safety measures. It is important healthcare organizations read and fully understand each year’s guide.
It is also important healthcare organizations train staff on emergency preparedness, data security, and HIPAA compliance. During the inspection, surveyors will not only ask staff about patient care. They will also ask about such things as communications during an emergency (in compliance with CMS’ Emergency Preparedness Rule), intradepartmental and interdepartmental communications (i.e. hand offs), and access procedures for EMRs and other technologies (passwords, authentication, etc.).
The following tips to help pass Joint Commission accreditation surveys might not apply to every type of healthcare organization in every circumstance. They are intended as a general guide that healthcare organizations can use to improve the likelihood of a successful survey and to achieve a better rating on the Joint Commission’s qualitycheck.org website.
Throughout the Survey Activity Guide, there are many references to the importance of having good communication systems in place - not only for professionals to collaborate of patient care, but also for healthcare organizations to comply with CMS’ Emergency Preparedness Rule. There will likely be more emphasis on communications if employee wellbeing is incorporated into next year´s standards.
Rave Mobile Safety is a leading developer of communication solutions for the healthcare industry. Our critical communications and response platform can improve patient care and resource coordination, help healthcare organization meet CMS mandates and requirements, and help prevent workplace accidents and workplace violence in order to keep employees safe. Contact us today to find out more.
Tara is a Marketing Coordinator on the Rave Mobile Safety marketing team. She loves writing about all things K-12 education, and manages the Rave social media channels. When she's not working, she's taking care of her smiley, shoe eating, Instagram-famous fur baby, Enzo!
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