How to a Survive a Joint Commission Visit

Markus Mainka/123RF.com

If you have been in healthcare longer than a minute, you know the fear that strikes your heart when you hear the dreaded announcement that “Jay-Co” (JCAHO, or the Commission on Accreditation of Healthcare Organization) is on the premises. Healthcare facilities pay JCAHO to assess their facility to determine if it meets their strident regulations. Accreditation by The Joint Commission is important for healthcare facilities because accreditation assures that the institution meets criteria related to the safety and quality of patient care, and JCAHO accreditation makes it possible for facilities to negotiate for higher reimbursement rates with private/commercial insurance companies.

Some visits are planned, and others are unannounced. Full surveys are done every three years. An organization can have an unannounced survey between 18 and 36 months after its previous full survey. In certain situations, you may get a seven day advanced notice. You, however, might get an unexpected call from your manager giving you notice that the surveyors are on their way to your unit. Once you’ve hidden your coffee mug, now what?

What does JCAHO care about?

Surveyors from JCAHO will ask questions that relate to their top priorities, including:

• Improving patient identification
• Improving communication between caregivers
• Improving accuracy of drug administration
• Improving drug documentation throughout the continuum of care
• Improving IV pump safety
• Maintaining accurate clinical alarms
• Eliminating wrong site, wrong patient, wrong procedure, or wrong surgery errors
• Reducing healthcare-acquired infections (HAIs)
• Reducing falls
• Addressing flu and pneumonia causes in older patients
• Reducing surgical or procedural fires

It’s not you

Remember that the visit is about the hospital, and not you as an individual staff person. While you may be interviewed and there are certain expectations you need to meet, the visit is not intended to catch you making mistakes. It’s to make sure health care facilities have systems in place to protect patients.

Get Ready for a Joint Commission Visit

Sometimes you have a heads-up when JCAHO is going to be visiting your hospital. Your hospital will likely send out emails (lots of emails) with instructions about how to answer sample questions, information on where to find policies and procedures, and other helpful tips. You should read these. You may have administrative staff walk through to offer a mock survey. Sample questions may include:

• Describe the process you follow when conducting the assessment for a new patient.
• What pain assessment tools do you use for initial assessment and re-assessment?
• How often is pain re-assessed?
• If a patient were to have a latex allergy, where would this be noted? How would it be communicated to other disciplines?
• How are patients screened for possible abuse (for example, elder, child, domestic violence, etc.)? What resources are available to you?
• How do you educate patients? Do you give them any written materials? Where is this documented in the patient record?

Pay attention

Pay careful attention to safety details around you – is everyone washing in and out and following hygiene protocols? What does your environment look like? Is there extra furniture in the hallway? Are fire doors blocked?

Know what you don’t know

I confess – right this minute I literally have no idea how to turn off the gas valve on my unit, and I’m not even sure I know where it is. And, if I’m honest, there is some medical equipment I’m not 100% positive I know how to clean the “right” way. If there is information you probably should know, then learn it. No, really - just go ahead and find out – it’s probably in the dusty manual in the corner of the workstation. If you can’t find the information, ask your manager.

It’s Ok Not to Know

If you are interviewed by JCAHO staff, it is possible you will be asked a question you have no idea how to answer. Never, ever say you don’t know the answer to a question. The correct response in that situation is always, “I am going to go find out the answer to that question.”

Take action

If the surveyor indicates something is raising a red flag, rectify it immediately if you can, and inform the surveyor it has been done. Then ask for feedback.

Quick tips:

• Be able to discuss two patient identifiers
• No medication overridden in the computer
• Document pain assessment and reassessment
• Know where your fire extinguishers are, and RACE/PASS
• Scan medications IN the patient's rooms; no scanning or drawing up in the hallway
• If using a computer on wheels and charting, have your back and the computer screen facing the wall