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Nursing’s role in Joint Commission accreditation

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By: Mark Pelletier, MS, RN

Inspiring safety and quality care.

Takeaways:

  • Nurses play a key role in the accreditation process and work on the frontline to prevent errors and promote quality and safety.
  • The Joint Commission supports and partners with healthcare organizations as they improve patient safety and care quality.
  • The Joint Commission employs more than 250 nurses to help develop and interpret standards and requirements and to work on advancing patient safety and quality initiatives.

As a private accreditor, The Joint Commission surveys healthcare organizations across all settings—hospitals, ambulatory care, behavioral health and human services, nursing care centers, assisted living communities, home care, and laboratories—for compliance with its accreditation standards. To keep patients, visitors, and staff safe, we conduct thorough on-site evaluations to assess care deficiencies and known and unknown risks. We strive to work with organizations to correct any deficiencies as quickly and sustainably as possible. Similar to the nursing profession, patient safety is at the core of The Joint Commission’s mission to continuously improve healthcare for the public. 

High reliability  

How do we achieve this common mission? As a quality improvement organization, The Joint Commission believes in high reliability as the answer to achieving our mission. This concept describes organizations and industries that maintain high levels of quality and safety over long periods of time with few if any adverse or harmful events, despite operating in very hazardous conditions.  

In healthcare, high reliability refers to consistently excellent and safe care across all services and settings. The three foundational, mutually reinforcing domains of high reliability consist of the following: 

  • Leadership commitment to zero harm
  • Establishment of a safety culture in which all employees speak up to prevent harm
  • Deployment of highly effective process improvement methods.

The Joint Commission Center for Trans­forming Healthcare (CTH) helps provid­ers across the continuum of care achieve zero harm. CTH collaborates with organizations to help transform healthcare into a high-reliability industry by developing effective, durable solutions to its most critical quality and safety problems.  

I encourage my fellow nursing colleagues to strive for zero harm. Speak up when you identify a safety concern or quality improvement opportunity. When you speak up, you not only protect patients and staff, but also drive significant and lasting change for your entire organization and community.  

Nurses’ critical role in accreditation 

The Joint Commission partners with and supports healthcare organizations on their quality improvement journey, but the organizations themselves drive quality and safety. Nurses have one of the most important voices within organizations, which is why The Joint Commission partners with them externally and internally. At 4.2 million strong, nurses are the backbone of U.S. healthcare. As professionals on the frontline of defense when it comes to preventing errors and promoting quality and safety, nurses have a strong role in the accreditation process.  

Nurses also play an important role. We employ more than 250 nurses, many of whom work as surveyors and reviewers within our accreditation and certification programs. Nurses develop and interpret Joint Commission standards and work on other patient safety and quality initiatives, including infection prevention and control, maternal health, suicide prevention, and workplace violence. 

Free resources for nurses

Accreditation isn’t about passing a test every 3 years. Instead, it’s about helping organizations and their staff, including nurses, to identify risk areas and providing them with the tools and resources to ensure quality and safety. 

Many nurses find these free tools helpful: 

  • Blogs and podcasts provide insights on pressing patient safety issues from Joint Commission and external subject matter experts.
  • Interpreting Joint Commission Standards: FAQs help find answers to the most common questions regarding Joint Commission standards. 
  • Joint Commission Online delivers weekly news about Joint Commission standards, on-site survey process, patient safety, and more.
  • Quick Safety advisories outline an incident, topic, or trend in health care that could compromise patient safety. 
  • R3 Reports expound on the rationale and references of new requirements from The Joint Commission. 
  • Sentinel Event Alerts periodically share current health care quality and safety issues.

Joint Commission standards 

You’ve likely heard the phrase, “It’s a Joint Commission standard and we could get cited,” as the rationale behind a policy or procedure. Many healthcare staff use this phrase to justify their current procedures. However, organizations and staff must move one step further. Rather than simply accepting that a requirement may be an accreditation standard, I challenge you to review closely the data-based rationale for particular requirements.  

I guarantee that The Joint Commission doesn’t make up standards or requirements just to be tough on an organization or to create busy work. Our standards form the basis of an objective evaluation process to help organizations measure, assess, and improve performance. They focus on patient, individual, resident, and organizational functions essential to providing safe, high-quality care.  

Input from healthcare professionals, pro­viders, subject matter experts, consumers, and government agencies factor into the development of Joint Commission standards. Informed by scientific literature and expert consensus, the standards must fulfill these objectives: 

  • relate to patient safety or care quality 
  • have a positive impact on health outcomes
  • meet or surpass law and regulation
  • can be accurately and readily measured.

Dispelling common Joint Commission myths 

In addition to misunderstandings about Joint Commission standards, other myths about accreditation exist. These harmful myths can spread quickly and lead to confusion. Because nurses engage so many levels and departments across their healthcare organizations, I frequently ask nursing colleagues to help dispel the most common myths.  

Myth 1: Healthcare workers should be fearful of The Joint Commission. 

Many healthcare professionals fear that The Joint Commission is out to take away an organization’s accreditation. That’s never the case. The Joint Commission partners with organizations to improve patient safety and quality of care. We strive for collaboration and work with organizations to identify and reduce risk. We recognize that no perfect healthcare organizations exist and that we far better serve the public when we work with organizations to identify and correct deficiencies. During on-site surveys, I encourage nurses to actively participate and empower themselves by asking surveyors questions and discussing improvement opportunities. 

Myth 2: The Joint Commission can shut down a healthcare organization. 

As a private accreditor (not a regulatory body), The Joint Commission has no authority to shut down a healthcare organization. Joint Commission’s accreditation is voluntary; however, it is associated with reputation and payor reimbursement. 

Myth 3: The Joint Commission issues frequent adverse decisions. 

The Joint Commission denies accreditation as a last resort if a healthcare organization has demonstrated a lack of capacity or willingness to resolve deficiencies. Adverse decisions are rare (3.64% in 2020). Although most organizations complete surveys without any adverse outcome, this doesn’t mean that Requirements for Improvement (RFIs) aren’t frequently identified. Rather, it means that the findings didn’t rise to a level of risk that makes them adverse. Organizations must complete a sustainable plan of correction for all RFIs.  

Myth 4: Joint Commission surveyors are just inspectors.  

Joint Commission surveyors and reviewers are highly trained doctors, nurses, hospital administrators, laboratory medical technologists, and other healthcare professionals. Their backgrounds allow them to collaborate in real time with leadership teams about how to solve quality or safety concerns. Surveyors describe being inspired by the many organizations they visit—learning about current innovative best practices and solutions implemented across the country. The surveyors enjoy sharing this wealth of knowledge with other healthcare organizations to help them implement improvement initiatives.  

Inspiring safety 

The Joint Commission values nurses. That’s why we appointed a nurse executive a few years ago, and for the first time in our history, the chair of our board of commissioners is a nurse. We strive with every encounter to inspire Joint Commission-accredited healthcare organizations to achieve greater patient safety. And we’re inspired when we help nurses improve their organizations and know that they share our mission to provide the safest and highest quality patient care.

Mark Pelletier is the chief operating officer and chief nurse executive at The Joint Commission in Oakbrook Terrace, Illinois. He welcomes your feedback at mpelletier@jointcommission.org

Reference 

Chassin MR, Loeb JM. High-reliability health care: Getting there from here. Milbank Q. 2013;91(3):459-90. doi:10.1111/1468-0009.12023 

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