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 acts as a symbol of quality that reflects an organization’s ability to meet certain performance standards. Accreditation, then, is highly sought and – once achieved – highly prized.
When healthcare organizations achieve Joint Commission accreditation, they are able to 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 it to prove they meet the standards required to receive payments from those federally funded programs. Organizations pursuing accreditation, along with those wishing to maintain accredited status, need to be permanently prepared for a surprise visit. Let’s walk through some tips that will help guide healthcare organizations to pass Joint Commission accreditation surveys successfully.
What happens during a Joint Commission accreditation survey?
When applying to be accredited, healthcare organizations are inspected by trained, certified “surveyors” comprised of highly experienced doctors, nurses, or other hospital administrators. These surveyors are chosen based on the individual organization’s need for accreditation.
During the inspection, or “survey,” the surveyors randomly select a patient’s medical records and use them as a roadmap to assess compliance with Joint Commission standards. The surveyors begin by tracing the patient’s experiences of their medical journey, talking with staff who have interacted with the patient and (if possible) with the patient themself. The environment in which the patient is cared for is also inspected to ensure compliance. All information is recorded and used in review to determine accreditation status. If compliance is found, the healthcare organization passes and is granted accreditation.
Once accreditation has been achieved, organizations have the duty of self-monitoring compliance with the Joint Commission’s standards and submitting data as proof every three months. This data relates to issues such as how they treat conditions like heart attacks and pneumonia. Repeat full accreditation surveys take place at 18-36 month intervals, but they are at random. Healthcare organizations are not warned in advance of a surveyor’s presence, which is why it’s imperative that an organization always be prepared when seeking accreditation.
These are standards that should be met all year, which is why repeat surveys are done at random. However, the Joint Commission’s standards are subject to change as the organization continues improving the standard of healthcare across the country. These changes are published in the Commission’s Survey Activity Guide for Healthcare Organizations ”and can be found here in .pdf format.
As you wait for your surveyor’s visit, it’s critical that your organization stay up-to-date on any changes in the activity guide to ensure no issues arise.
Tips for passing Joint Commission accreditation surveys
The following tips for passing Joint Commission accreditation vary depending on the type and specific circumstances of the healthcare organization in question, but overall can be used as a general guide for improving the likelihood of having a successful survey and achieving a better rating on the Joint Commission’s qualitycheck.org website.
Identify discrepancies between the guide and current practices
The most recent activity guide, released in January 2022, is 142 pages in length. It is organized by types of healthcare organizations, so you won’t need to worry about studying it cover to cover. Discrepancies between the Joint Commission’s standards and current working practices are outlined for each type of organization, and if any apply to your specific case, they must be remedied before a Joint Commission accreditation survey in order to pass. To make it even simpler to note the discrepancies and updates, new or revised content by year is identified both at the beginning of the activity guide along with being underlined throughout the guide.
Learn from others’ mistakes
The Joint Commission publishes a list of the most frequently cited failings from inspections during the previous year in its “Perspectives” newsletter, which comes out every April. The reasons that a healthcare organization fails usually have little to do with the standard of care provided, and are more likely attributed to the environment of care lacking something necessary for passing the Joint Commission standard.
Every healthcare setting has a different standard environment of care that differs greatly from one another. Assisted living communities are going to have a very different standard of care from a laboratory, pharmacy or ambulatory service. Every different organization section in the activity guide has a subsection on “Environment of Care” that will list exactly what needs to be done so that you pass all aspects of the survey, which is why reading the survey activity guide closely is so important to success.
Make a good first impression
The Survey Activity Guide also pays a significant amount of attention to how an inspector should be greeted, how they should be identified and how they should be accommodated. Make sure your organization’s “welcome team” is up-to-speed with the current recommendations and always have a clean office space available for the surveyor to work from.
Another “housekeeping” step to prepare for a successful survey is to clean corridor clutter. In the event of an emergency, it makes it harder to move patients, but it can also hinder patient response and safety. There is certain medical equipment that the Joint Commission acknowledges as important to be permanently accessible in the corridor, so make sure you know what those items are and remove any that don’t appear on the list.
Train your staff to be prepared for anything
To achieve or maintain accreditation, it is important that 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 things like:
- Communications during an emergency (in compliance with CMS Emergency Preparedness Rule)
- Intradepartmental and interdepartmental communications (i.e., hand-offs)
- Access procedures for EMRs (electronic medical records) and other technologies (passwords, authentication, etc.).
While you can’t prepare for when the surveyor will actually show up, you can still make other preparations in training, organizing, researching and updating.
Preparedness is key
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 on patient care but also for healthcare organizations to comply with the CMS Emergency Preparedness Rule. There will likely be more emphasis on communications if employee wellbeing is incorporated into future 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, as well as help healthcare organizations meet CMS mandates and requirements. With a critical communication system, healthcare organizations can also help prevent workplace accidents and workplace violence in order to keep employees and patients safe, all of which improve outcomes for Joint Commission surveys.
For more information on a critical communication and collaboration platform specifically built with healthcare organizations in mind, check out Rave & AppArmor for healthcare facilities and download the info sheet.