An Insider’s Look at Meeting Joint Commission Guidelines

Accreditation by the Joint Commission—the largest and most prestigious of the healthcare industry’s accreditation agencies—is not mandatory, but it’s highly desirable. About 77 percent of hospitals in the United States currently have Joint Commission accreditation. Every three years, to maintain their Joint Commission accreditation, healthcare organizations must prove that they’ve met the commission’s rigorous standards for performance and service.

The stakes are high—and the process is thorough and demanding.

“It’s extremely nerve-wracking to go through a Joint Commission survey,” acknowledges Shaefer Spires, M.D., an epidemiologist and physician chair of antimicrobial stewardship for Williamson County Medical Center in Franklin, Tennessee, echoing the feelings of most healthcare providers. Yet the act of preparing for a survey visit can be the necessary catalyst for ramping up a facility’s quality of care and prioritizing patient safety.

Why the Gold Seal Matters

The Joint Commission tracks more than 250 hospital accreditation standards—and experts are constantly refining and updating them to make sure they reflect the latest evidence. The standards address everything from patient rights and education, infection control, medication management and preventing medical errors, to how the hospital verifies that its personnel are qualified and competent, and how it collects and uses data on its performance. Other types of healthcare organizations, including behavioral health organizations and home healthcare agencies, are also eligible for accreditation by meeting standards for their facility types.

Focusing on meeting the standards should be among an organization’s top priorities, says Angie Mitchell, RN, former director of nursing services, clinical operations for HealthTrust. Accreditation has financial ramifications: Many insurance companies won’t reimburse an organization that isn’t accredited, and hospitals lacking the designation risk losing their credibility with patients and the public.

That Gold Seal of Approval is not only validation of an organization’s hard work—it’s also an important symbol for patients and their families, even if they don’t necessarily know everything that goes into becoming accredited, says Michael Greer, RN, MHA, senior director of regulatory and accreditation at LifePoint Health. “The Gold Seal shows that our hospitals have met high standards.”

Always Ready

The Joint Commission doesn’t announce its visits in advance. The survey team makes a surprise appearance at an organization 18 to 36 months after its previous full survey.

Ongoing preparation is key, Mitchell says. “The Joint Commission can come in anytime, and you don’t know until the day of.”

Although it’s typical for facilities to ramp up efforts when a visit seems imminent, “if you’re doing what it takes for quality improvement, then a Joint Commission visit is just another day,” Spires says.

In fact, everyday excellence—not a one-off scramble to meet the assignment—is the goal. To that end, the Joint Commission provides facilities with a self-assessment scoring tool to help them stay on track with standards compliance. Meeting and maintaining those standards should be “woven into the fabric of a healthcare organization’s operations,” as the commission says on its website.

Because the Joint Commission survey team might ask for cleaning or maintenance information during its visits, Mitchell suggests leaning on suppliers to provide those details. If suppliers offer specialized training or value-added programs such as preventive equipment maintenance, offer that information to the survey team, she advises.

“As HealthTrust looks at contracts, the question of where and how this equipment will be used is always at the back of our mind,” Mitchell says. “Is this something that the Joint Commission is going to come in and ask about?”

Auditing for Risks

No hospital runs flawlessly. All facilities—even among the nation’s best hospitals—have something that can be enhanced. That’s why it’s important to make a self-assessment plan that includes metrics ensuring that improvement processes are in place and necessary changes are made.

Some organizations choose to contract with a consultant to gain insight into areas where they need to focus their energies. Mitchell says a consultant can bring a fresh set of eyes and an impartial view that can benefit many organizations when they’re trying to determine what needs improving.

At LifePoint Health, Greer heads up a team of subject matter experts assisting LifePoint facilities in measuring up to the Joint Commission’s standards. He estimates that he’s on the road visiting facilities about 50 weeks of the year.

During the visits, called “survey readiness assessments,” the team assesses the hospitals to identify risk areas. If they fall short in a particular area, the hospital team must develop a corrective action plan to help them get back into compliance. The subject matter experts work with facility leaders to provide support and ensure the necessary progress is made. The team returns to the hospital a few months later to conduct a follow-up survey.

The process, in place for about a decade, has been well received by LifePoint’s facilities, Greer says. In fact, hospital leaders call him, eager to schedule a visit. “They consider it a value-added service,” he says.

Keeping the Motive in Mind

The Joint Commission regularly updates its standards, requiring hospitals to monitor for changes and adjust accordingly. It can help to remember the overarching goal of Joint Commission standards: safe, high-quality patient care. Spires underscores that these requirements aren’t arbitrary, or merely bureaucratic paperwork. “The Joint Commission’s motive is patient safety,” he says.

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