Plan ahead and collaborate for success.
Many healthcare organizations find preparing for regulatory and accreditation surveys challenging. Between the unannounced aspect of surveys and everyday challenges, such as staffing shortages and varying patient acuity, achieving regulatory readiness may seem low priority. Although some healthcare organizations merely hope for the best when The Joint Commission visits, many others develop internal processes to help staff prepare.
You and your nurse colleagues may have some misconceptions about The Joint Commission and accreditation. Unpacking any misunderstandings can help you and your organization achieve a culture of safety and recognize the value of the accreditation process. Below, I answer some common questions related to The Joint Commission and the survey process.
Why do I have to be accredited by an organization like The Joint Commission?
The Centers for Medicare and Medicaid Services (CMS) provides federal oversight of care quality in all U.S. hospitals that receive Medicare and Medicaid funding. Hospitals that accept patients with Medicare or Medicaid insurance (approximately 61.4 million have Medicare, Parts A and B, and 75.8 million have Medicaid) must meet conditions of participation mandated by CMS to receive reimbursement. CMS requires that these hospitals have accreditation from one of 10 accrediting organizations, such as The Joint Commission. CMS also provides oversight of The Joint Commission’s survey process to ensure it meets or exceeds the conditions of participation.
An accreditation survey can happen at any time of day, during any day of the week. Healthcare organization leaders have responsibility for ensuring they’re prepared for a survey, whether it’s announced or unannounced. Some nurses, especially new graduates, have reported that they feel unprepared for accreditation surveys, in which they may have to recall information and data that are not top of mind. Surveys can happen while nurses are in the midst of caring for patients. Surveyors actually prefer speaking to a nurse who’s caring for a patient they’re tracing (auditing from hospital admission until discharge) or other frontline staff member about relevant policies and procedures.
Organization leaders can take several steps to engage frontline nurses and staff and help them connect the dots among accreditation, patient safety, and outcomes. Leaders also can make hardwired changes that ensure the organization meets accreditation standards and promote and increase patient, staff, and visitor safety.
How do I debunk common misconceptions about The Joint Commission?
Some of the more common misconceptions of The Joint Commission are related to the enforcement of supposed rules, such as no water at the nurses’ station, staffing-level regulations, and no parking beds in the hallway. As a leader, I experienced these same issues for years as we prepared for upcoming surveys. And without fail, the organization would initiate an employee engagement survey at the same time, leaving leaders struggling to enhance their units while nurses voiced frustration with what they perceived as trivial rules, which exacerbated leaders’ disdain for accreditation surveys.
My experience as a nurse, leader, and member of an internal team conducting mock evaluations for hospitals that were due for their triennial survey allowed me to identify a few easy strategies for promoting positivity around these activities. For example, within nearly every healthcare unit, you can find a nurse who wants to enhance their knowledge of the accreditation process and learn how to successfully pass surveys. This may be a newer nurse with a fresh passion for patient care or a more seasoned nurse with years of experience who has established themselves as an informal leader within the unit. You can identify these professionals by their willingness to answer questions and their pride in showing off their unit.
After identifying that nurse champion, let them shine. Give them ownership (with supervision) over The Joint Commission survey unit readiness. Teach them how and where to access the standards, and allow them to oversee other staff to ensure they’re performing successfully. If issues arise, guide the champion in addressing them with their peers. In addition, help these informal leaders speak to their peers about why procedures must change to successfully complete a survey.
Ultimately, nurses’ interactions with surveyors will be key to reversing some long-standing myths associated with The Joint Commission and its mission. The educational and collaborative experience nurses gain when interacting with The Joint Commission helps to expose them to what the organization truly is: an accreditor working to ensure that the organization provides the highest quality of care.
What’s an example of a misunderstood “rule”?
No beverages at the nursing station is one of the most common misunderstood rules. It’s been a topic of debate for years, and until I read the standards myself and understood how to apply them, I didn’t appreciate the why behind this rule.
In fact, this “rule” doesn’t come from The Joint Commission. Rather, it falls under the leadership standard (LD.04.01.01), which requires a hospital to follow licensure requirements, laws, and regulations. In this case, that includes The Occupational Safety and Health Administration’s (OSHA’s) Bloodborne Pathogen Standards (1910.1030(d)(2)(ix)), which prohibits the consumption of food or drink in areas where work occurs that involves exposure or potential exposure to blood or other infectious or toxic materials. The standard goes on to describe assessments for locating areas (hydration stations) with staff access to water and other beverages. Frequently, these stations are located in the core of a nursing station. In addition to protecting food and drinks from contamination, the standard also protects equipment and charts from spills that could cause permanent damage.
Explaining the rule in a way that makes sense to nurses and staff helps to enhance understanding and acceptance. If not adequately explained, myths can expand and potentially damage morale. When the unit champion understands the reasons behind this and other similar rules, they can correct misperceptions and help others navigate conversations with The Joint Commission.
How can I prepare for The Joint Commission’s arrival?
One large multihospital healthcare system has had a robust process in place for years, which includes an internal team that evaluates hospitals for CMS and Joint Commission regulations and standards before upcoming triennial surveys. Originally, after the mock surveys, the team provided findings and left the hospitals to make corrections before The Joint Commission’s arrival. However, several hospitals consistently received a serious finding (condition-level deficiency [CLD]) from The Joint Commission each year. CLDs are high-risk, frequently widespread findings that require immediate intervention and a resurvey by The Joint Commission to ensure compliance.
To address the recurring CLDs, the organization implemented a quality improvement project. After the internal team completed its survey and issued its report, the project leader made a series of calls to guide the hospitals through a correction plan process, help reduce or eliminate barriers to correcting issues, and ensure the new process continues over time. The project leader, a member of the internal survey team who worked in the healthcare organization’s corporate offices, owned the process and served as the point of contact for all hospitals. The process took 90 days and included a 14-day, 30-day, 60-day, and 90-day call. If outcomes weren’t being met sufficiently, additional calls could be scheduled.
Comparative analysis of requirements for improvements (RFIs) and CLD data obtained from reports produced post-survey measured differences in accreditation outcomes before and after implementing the correction plan. Of the 16 hospitals that participated in the project through the 30-day plan of correction call, only two (13%) received a CLD. Among the six hospitals that didn’t participate, all received a CLD. The number of RFIs from the hospitals that completed at least the 30-day call were significantly lower (P = .017) than those that didn’t participate. The process successfully reduced the number of hospitals in the healthcare system that received a CLD during their Joint Commission triennial survey.
One of the key factors included categorizing and prioritizing the internal team’s findings similarly to The Joint Commission. “Major” findings aligned with CLDs, and “important” and “general” findings aligned with standard RFIs as found in a survey by The Joint Commission. Prioritizing findings when reporting them to the hospitals and then focusing on major findings first led to greater compliance with the standards. In addition, barriers (finances, policy changes) typically associated with resolving major findings were either mitigated or eliminated with help from the project leader.
We don’t have an internal team. How can I help my unit?
Leaders can implement various interventions to help their units prepare for accreditation surveys. Consider creating a unit-level, internal mock survey with the identified unit champion serving as the surveyor. Connect the champion with the resources to understand The Joint Commission standards and how they’re applied in practice. You can find several tools to aid mock survey development and implementation of a unit-based correction process at jcrinc.com. Leaders play a key role in providing oversight to help hardwire changes and monitor them for compliance over time. (See Get prepared.)
It’s survey day. Any tips?
Several procedures can help a survey go as smoothly as possible. Ensure that the unit champion works on the day of the survey. If they’re engaged and willing, ask them to speak with The Joint Commission surveyors. Although surveyors can speak to anyone they encounter, one engaged nurse willing to speak with them is sufficient. Encourage other staff to continue with their usual procedures and practices.
Create a checklist for the survey day to ensure completion of all tasks. Remind staff that they have time. The Joint Commission usually arrives in the morning after sending an email to a designated employee to announce that they’re coming. Surveyors typically need time to settle in and participate in an opening conference before they start surveying the units. During this time, staff can run through their checklists and call for the unit champion.
To help shift any negative attitudes staff might have about The Joint Commission, allow as many nurses as possible to interact with the surveyors. The Joint Commission promotes a collaborative and educational approach with nurses and hospitals. Its goal and mission are parallel to that of most hospitals: Improve the lives of patients and ensure the best healthcare possible.
We did it! How can we keep the momentum going?
Continued engagement after The Joint Commission or other accrediting bodies have completed their survey helps to achieve a successful overall process. If a hospital receives a CLD, a resurvey by The Joint Commission will occur during a return visit. The resurvey focuses on the CLD finding and work taken toward a resolution. This doesn’t mean that the hospital only has to worry about what was found by The Joint Commission. CMS will perform a full survey and frequently focuses on different standards from The Joint Commission. In addition, CMS can use The Joint Commission report to validate that necessary changes have been made or are being implemented. Losing the ability to receive Medicare and Medicaid payments is among the harshest consequences a hospital can receive.
After survey completion, staff should take time to celebrate as a unit. Recognize the toll survey week can take on staff and remind them through continued engagement of the need for ongoing vigilance. Maintaining compliance requires that leaders prevent the unit from reverting to workarounds and making the same mistakes it made before the survey. You want to ensure staff understand the reasons behind The Joint Commission standards and how they promote patient safety and improved outcomes. Making these connections can help ensure practices learned during the survey become automatic and natural. In addition, any previous misperceptions about accreditation will slowly reverse so that the culture becomes one of collaboration with the belief that, together, the healthcare organization and The Joint Commission can provide the highest level of patient safety.
Carla Pierson is director of nursing services and clinical operations at HealthTrust Purchasing Group in Nashville, Tennessee.
American Nurse Journal. 2023; 18(7). Doi: 10.51256/ANJ072339
Centers for Medicare and Medicaid Services. FY 2018 Report to Congress (RTC): Review of Medicare’s program oversight of accrediting organizations (AOs) and the clinical laboratory improvement amendments of 1988 (CLIA) validation program. August 20, 2019. cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-17-AO-CLIA.pdf
Centers for Medicare and Medicaid Services. CMS fast facts. March 2023. data.cms.gov/sites/default/files/2023-03/CMSFastFactsMar2023.pdf
Hempel EV, Duca N, Kipp R, van Harskamp J, Caputo G. Preparing for the new Joint Commission requirements: A model for tracking outcomes of an ambulatory antibiotic stewardship program in primary care. J Gen Intern Med. 2021;36(3):762-6. doi:10.1007/s11606-020-06365-1
The Joint Commission. All Accreditation Programs Survey Activity Guide. January 2021. jointcommission.org/-/media/tjc/documents/accred-and-cert/survey-process-and-survey-activity-guide/2021/2021-all-programs-organization-sag.pdf
The Joint Commission. 2023 Comprehensive Accreditation Manual. store.jcrinc.com/2023-comprehensive-accreditation-manuals
The Joint Commission. The unannounced survey process fact sheet. jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-the-unannounced-survey-process
Occupational Safety and Health Administration. Bloodborne pathogens standard 1910-1030. osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030
Pierson CS. Evaluation of Action Plan Management Strategy to Improve Survey Readiness and Decrease Negative Accreditation Findings [dissertation]. Minneapolis, MN: Walden University College of Nursing; 2022. proquest.com/openview/4e90b7577eaa02be35158b2ee4c5c2a2/1?pq-origsite=gscholar&cbl=18750&diss=y
Watson Campbell R, Leger JM. Preparing for a Joint Commission survey: An innovative approach to learning. Nurs Educ Perspect. 2020;41(5):315-6. doi:10.1097/01.nep.0000000000000708
Key words: accreditation, The Joint Commission, action planning