Are you patient-ready? Preparing for The Joint Commission

We recognize the name, but who exactly is The Joint Commission? And what do they do?

The Joint Commission is an independent non-profit organization that evaluates health care systems on their ability to provide safe and effective care to patients.

For health care organizations seeking The Gold Seal of Approval®, the Joint Commission sends a group of surveyors once every three years to perform an unannounced survey of quality and safety standards.

What happens during a survey?

All regular Joint Commission accreditation surveys are unannounced. For UI Hospitals & Clinics, a specially trained Joint Commission team of 10-12 surveyors will assess our organization’s compliance to Joint Commission’s standards during a five-day survey. They will also evaluate our policies and procedures and verify that the care we provide our patients is appropriate.

During the survey, surveyors will visit all areas of our buildings including, but not limited to inpatient units, clinics, procedural areas, operating rooms, and pharmacies. While visiting these areas, surveyors will select patients randomly and use their medical records as a roadmap to evaluate standards compliance. These are called tracers. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe staff caring for patients, and often speak to the patients themselves.

Surveyors will also evaluate our facilities and review our life safety systems and documentation as well as our compliance with Environment of Care standards, staff files, performance improvement processes, and emergency preparedness plans.

Why is this important?

A successful survey is very important for many reasons. Most importantly, the Joint Commission’s review of our organization’s performance helps to validate that we are providing safe and high quality care for all patients and in a way that offers value.

Also, hospitals who receive funding from Centers for Medicaid & Medicare Services (CMS) must meet Conditions of Participation.  A successful survey by The Joint Commission meets CMS’ Conditions of Participation which is required to receive Medicaid & Medicare payment.

Finally, having outside surveyors review our hospital provides us an opportunity to showcase the many ways we meet or exceed the required standards. It also allows us the ability to “exchange notes” with our surveyors to hear how other organizations are dealing with similar challenges we experience in an effort to continue to grow and improve.

Are we patient ready?

A visit from the Joint Commission often prompts the question, “Are we ready for the survey?” While it’s a fair question, it can direct attention away from what matters most: our patients.

Our protocols and policies are not in place for the Joint Commission, they exist—and we follow them—because it’s the right thing to do for our patients and visitors to keep them safe.

At its core, the Joint Commission survey is simply a benchmark of our hospital’s quality and safety standards. If we’re diligent and mindful of maintaining a safe environment day in and day out, a visit from the Joint Commission becomes just another week.

So, while it is important to be prepared when they arrive, the real question isn’t, “Are we ready for the Joint Commission?”

The question is…

  • Are we following the processes in place to help provide the best quality care we can?
  • Are we following current policies and protocols to prioritize safety?
  • Are we prepared each day to care for our patients in the way they deserve?

…are we patient ready?