Educate Your Facility for the Joint Commission Survey

If you’ve been around the healthcare industry for a while, you’ve certainly heard of The Joint Commission (TJC) — a regulatory body providing standards of safety in medical centers around the United States. While a basic level of understanding is important, it’s even more important that you can confidently navigate the process of obtaining TJC accreditation and how to maintain optimal patient care through operational excellence. 

There are so many elements that go into TJC surveys, accreditation, compliance, and more, so we’re going to dive into exactly what you need to know to breeze through the survey process, keep your standards high, and provide an excellent level of patient care as a result.  

Understanding TJC Standards for Better Compliance

A general understanding of TJC standards is great and certainly helpful, but the true benefit of The Joint Commission’s guidelines and best practices lies in understanding them on a deeper level. Most healthcare professionals have at least a general idea about TJC standards, but it takes more than broad knowledge to practically implement the standards in a meaningful way. 

Why are certain standards in place? How can you best implement them? What changes might you need to make to better align with the standards? The answers to these questions and more may not be something that you’re able to answer fully with only a surface-level understanding. Consider implementing resources like a Joint Commission survey readiness checklist or Joint Commission mock survey checklist to help prepare your team for what to expect and how to navigate the preparation process. 

The best way that you as a facility manager can empower your construction crews, medical staff, and admin teams to support an overall healthy and compliant facility is by educating them and providing ongoing training, as well as infection control certifications where appropriate. When everyone understands the goal of compliance with TJC, you’re much more likely to provide a safe and healthy facility to the community. 

What Do The Joint Commission Standards Cover?

The Joint Commission’s standards are designed to promote patient safety and quality of care around your facility. As you can imagine, this covers a wide variety of areas and processes. In fact, the total number of standards reaches more than 250 and is updated all the time to reflect the most accurate and up-to-date advancements in healthcare and medicine. 

Some of the main categories that you can expect to see in TJC standards include: 

Patient Rights and Education: Ensuring that patients are fully informed about their care, treatment options, and rights.

Infection Control: Implementing strict processes to prevent and control infections within your healthcare facility.

Medication Management: Managing medications safely and effectively, from prescribing to administration.

Preventing Medical Errors: Establishing systems to identify, report, and prevent medical errors.

Staff Qualifications and Competency: Verifying that all healthcare providers are qualified and competent to perform their duties.

Emergency Preparedness: Preparing for and responding to emergencies to ensure patient and staff safety.

Data Collection and Performance Improvement: Collecting data on performance and using it to drive continuous improvement in care quality.

Best Practices for Joint Commission Compliance 

Maintaining accreditation over time requires that your facility has procedures in place to ensure that strict standards are met regularly — not just during a survey. To do this, you’ll need to implement strategies like ongoing monitoring, detailed documentation, and continuous improvement. 

Ongoing Monitoring

Whether before a survey to decide onthe next steps or after accreditation to maintain high standards, monitoring allows you to see the full picture of how your facility is performing on a regular basis. 

A few ways to implement ongoing monitoring include: 

• Regular Audits: Conduct regular internal audits to assess compliance with Joint Commission standards. These audits should be comprehensive and cover all relevant areas, including patient care, infection control, and medication management.
• Use of Technology: Implement technology solutions such as electronic health records (EHRs) and compliance management software to track and monitor compliance. These tools can provide real-time data and analytics to help identify areas needing improvement.
• Performance Dashboards: Develop performance dashboards that provide at-a-glance views of key compliance metrics. This helps facility managers and staff quickly identify and address any areas of concern.
• Staff Involvement: Engage all levels of staff in the monitoring process. Encourage them to report potential issues and participate in regular compliance reviews.

Documentation

Accurate and thorough documentation ensures that all activities are traceable and verifiable, which is essential during audits and surveys. 

Documentation includes: 

• Consistent Record-Keeping: Maintain consistent and detailed records of all compliance-related activities. This includes patient care records, incident reports, training logs, and audit results.
• Standardized Forms and Templates: Use standardized forms and templates to ensure that documentation is consistent across the organization. This helps avoid discrepancies and makes it easier to compile and review records.
• Document Management System: Implement a robust document management system to organize and store all compliance-related documents. This system should allow for easy retrieval and secure storage of records.
• Regular Reviews: Schedule regular reviews of documentation to ensure accuracy and completeness. This helps identify any gaps or errors that need to be addressed.

Quality Improvement

Excellence doesn’t stop with compliance and accreditation. Your facility’s commitment to health and safety should be reflected in your pursuit of ongoing improvement. 

Quality improvement measures might include: 

• Performance Improvement Projects: Initiate performance improvement projects to address identified gaps and enhance overall compliance. These projects should be data-driven and focused on specific areas of need.
• Root Cause Analysis: Conduct root cause analyses to understand the underlying causes of compliance issues. This helps develop effective corrective actions and prevent recurrence.
• Staff Training and Education: Provide ongoing training and education for staff on best practices and new developments in healthcare standards. This ensures that everyone is informed and equipped to maintain compliance.
• Patient and Staff Feedback: Collect and analyze feedback from patients and staff to identify areas for improvement. Use this feedback to inform quality improvement initiatives and enhance care delivery.
• Benchmarking: Compare your facility’s performance against industry benchmarks and standards. This helps identify best practices and areas where the facility can improve.

Creating a Post-Survey Plan to Align With TJC Standards

Once you have your final survey findings from a Joint Commission survey, it’s time to review them and create a plan to correct any gaps. To do this, make sure you first have a deep understanding of both the standards and how your facility currently operates. This will allow you to better address the discrepancies and make strides towards full compliance. 

Often this will mean that you’re pinpointing areas where the current response strategy lacks thoroughness, fails to adhere to best practices, or does not consider long-term sustainability. It may also involve identifying specific weaknesses in your monitoring strategies and ensuring compliance with these plans. When you have identified the problem areas, you’re ready to create a plan of attack to close the gaps that the TJC surveyor identified. 

5 Ways to Close the Gaps in Your TJC Survey Findings

1. Engage Key Stakeholders

Involve department heads, frontline staff, and other relevant personnel in the planning process. Their insights and experiences can help identify practical solutions and foster a sense of ownership and commitment to the corrective actions.

2. Set Clear, Measurable Goals

Define what success looks like for each corrective action. Use SMART (Specific, Measurable, Achievable, Relevant, Time-bound) criteria to ensure your goals are clear and achievable. This helps in tracking progress and making necessary adjustments.

3. Utilize Data and Technology

Leverage data analytics and technology to monitor progress and identify areas needing further improvement. Implement electronic health records (EHRs) and compliance management software to track compliance in real time.

4. Implement Feedback Processes

Establish channels for staff to provide feedback on the implementation of corrective actions. This feedback can offer valuable insights into what’s working and what needs adjustment.

5. Review, Adjust, and Communicate

Regularly review the progress of your corrective actions and be prepared to make adjustments as needed. Also, take care to communicate your findings to all of the stakeholders so that everyone can understand the progress being made.

How to Get Your Staff Educated and On Board With Compliance

Guaranteeing that all levels of staff are engaged and understand their role in TJC compliance and the survey process can be a major challenge. Typical training efforts focus on managers, leaving frontline staff less prepared. However, for a healthcare facility to achieve and maintain Joint Commission standards, everyone — from administrators to clinical staff — must be knowledgeable and equipped to support compliance. So, take care to keep everyone in the loop with surveys, results, strategies, and improvements. With everyone on the same page, you’re able to work as a team where everyone feels invested in the success of the facility in TJC compliance. 

Start by developing (or hiring out) comprehensive training programs that cover all aspects of the Joint Commission standards. Tailor these programs to different roles within the organization to make sure that each team member understands their specific responsibilities. Regular workshops, seminars, and e-learning modules can keep everyone up-to-date on the latest standards and practices to support your commitment to compliance. 

Proactive Risk Management for TJC Compliance

Mitigating risk in your organization is always important, but it’s much more so specifically when you’re preparing to go through your Joint Commission survey and afterward when you’re maintaining your compliance and accreditation. 

You can do this by:

Identifying Risks Regularly

To meet Joint Commission standards, identify specific risks in your facility such as infections, medical errors, and maintenance issues. Regularly conduct risk assessments and use the data to pinpoint areas in need of improvement.

Implementing Security Measures

Implement strict security protocols to safeguard patients, staff, and assets. This includes verifying visitor identities, managing access to sensitive areas, and utilizing technology solutions like surveillance systems and access controls to enhance security.

Prioritizing Continuous Improvement

Continuously review and update your risk management policies based on industry best practices and lessons learned. Regular policy reviews and staff training are essential to ensure everyone is prepared for potential risks and aligned with Joint Commission standards.

Joint Commission Compliant Healthcare Made Simple

Navigating the Joint Commission survey process and maintaining accreditation requires a comprehensive and proactive approach. By deeply understanding the standards, engaging and educating your staff, implementing risk management and security measures, and continuously striving for improvement, your facility can achieve and maintain high levels of compliance and quality care.