Are We Ready for Joint Commission?

Ensuring that an organization is ready for an accreditation, licensing and/or certification is an on-going process not a one-time activity. It can be beneficial to utilize tools in order to define the process to ensure compliance with standards and guidelines and to gain commitment from the stakeholders by involving them in the process with specific responsibilities relating to their organizational areas and areas of expertise. There are two parts to this assignment to prepare a hospital for a Joint Commission Accreditation Survey. Note that although this is for Joint Commission a similar process can be used to prepare for a licensing survey or other accrediting body.

1. Open the document titled “Accreditation Survey Activity Guide for Health Care Organizations” by clicking on the link below. Review the document to become familiar with the areas that a hospital would need to assess in order to ensure organization wide readiness for a Joint Commission Accreditation Survey. 

For this assignment you will review the section on Leadership and Data Use, page 83.

Based on the information provided in this section of the areas that the surveyor will review with leadership at the time of the survey, create an assessment document that you would have used to perform the organizational assessment for each of the eight areas in the Leadership and Data Use Overview. Include what information/reports you would have required and from which stakeholders. This can be done in a table or spreadsheet (see example below). See the list of possible leadership stakeholders below.

Topic	Stakeholder	Activity for Preparation	Outcome
Monitoring Performance of Contracted Services	-Vice President of  Operations  -VP and Department  Directors with  Contracted   Services -Legal Counsel-	List of all contracted services agreements Identify service provided for which area (Nursing, HIM, etc) Identified performance expectation in agreement  Performance monitors in place with timeline and benchmarks	Report on contractor performance and recommendations to continue or cancel.

Accreditation Survey Activity Guide for Health Care Organizations

2. Open the document title “Checklist for Joint Commission Preparation Readiness” by clicking on the link below. This document includes a checklist of activities to prepare the organization for survey immediately before the survey team arrives. Reorganize the checklist in a table or spreadsheet format to identify and assign specific responsibility for each activity, supporting what needs to be done. Utilize the list of leadership positions below and your knowledge of hospital organization. It would be leadership’s responsibility to assign the tasks to those Directors under their area of responsibility.

Example

Preparation Activity	Responsible Leader	What Needs to Be Done
No patient names are easily visible	Vice President of Nursing (Charge Nurse for each unit and ED Vice President of Finance(Director of Admissions and Director of HIM)	Check all patient rooms and nursing stations to be patient names are not visible to visitors Check all areas within the department to ensure patient information on screens and paper records is not visible to non-authorized users

Checklist for Joint Commission Preparation Readiness

· CEO

· Vice President of Operations (includes all operational areas in the hospital including Environmental, Clinical and Nursing – the VP’s for these areas report to the VP of Operations

· Vice President of Finance (Director of HIM)

· Vice President of Nursing

· Vice President of Clinical Services

· Vice President of Medical Affairs

· President of the Medical Staff

· Vice President for Performance Improvement

· Vice President of Environmental Affairs

· Senior Director of Risk Management