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.
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.
However, other than the “Early Survey Option” at the start of the accreditation process, Joint Commission Accreditation Surveys are rarely announced in advance. Therefore, organizations pursuing accreditation and those wishing to maintain accredited status need to be permanently prepared for a surprise visit. In this blog, we share five tips to help healthcare organizations pass accreditation surveys.
What is a Joint Commission Accreditation Survey?
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 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.
Once accreditation has been achieved, 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.
It’s Not Possible to Prepare for an 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 are subject to change as the organization strives to improve the standard of healthcare across the country.
Changes are most often published 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.
To achieve or maintain accreditation, it is important 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.).
5 Tips to Help Pass Joint Commission Accreditation Surveys
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.
- Identify Discrepancies between the Guide and Current Practices
Although the current Survey Activity Guide is 120 pages in length, once you take out the areas that do not apply to your type of healthcare organization, it is simpler to identify discrepancies between the Joint Commission’s standards and current working practices. These discrepancies need to be remedied before a Joint Commission accreditation survey.
- Learn from Other Organizations’ Failings
Each year (usually around April), the Joint Commission publishes a list of the most frequently cited failings from inspections during the previous year in its “Perspectives” newsletter. Often the failings have little to do with the standard of care provided by the healthcare organization and are more likely attributable to the environment of care.
- Get Rid of Corridor Clutter
In the event of an emergency, corridor clutter not only makes it harder to move patients, but it can also hinder emergency response. The Joint Commission acknowledges that some medical equipment needs to be permanently accessible, but inspectors have previously found items such as laundry baskets obstructing corridors for hours
- You Never Get a Second Opportunity to Make a Good First Impression
In the Survey Activity Guide, a significant amount of attention is given to how an inspector should be greeted, how he or she should be identified, and how he or she should be accommodated. Make sure your organization’s “welcome team” are up-to-speed with the current recommendations, and always have ready a clean, Internet-connected office space from which the inspector(s) can work.
- Keep up to date with Joint Commission’s Current Hot Topics
On the Joint Commission’s website, there is a frequently updated blog which is a good thermometer of the Joint Commission’s current “hot topics”. Recently the blog has covered such topics as improving health and safety in healthcare workspaces and protecting staff from workplace violence – implying that employee wellbeing may be incorporated into future standards.
Improve Communication and Protect Employees
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 future standards.
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