Quality team update - Joint Commission Survey readiness
by Mohsina Yusuf
To maintain continuous high-quality care, Emory Healthcare conducts mock surveys, tracers, and environment of care and infection prevention rounding. This ongoing assessment throughout the three-year cycle of accreditation from the Joint Commission (JC) addresses areas of risk to help prepare for the next on-site survey conducted by the JC. Emory Healthcare teams round throughout the hospital with JC checklists to confirm JC standards are met.
The Joint Commission (JC) is a not-for-profit accrediting organization globally recognized for offering unbiased assessments of quality achievement in patient care and safety. Its helped hospitals transform their practices by meeting rigorous performance standards for nearly 70 years. JC works with tens of thousands of organizations, giving powerful perspective into the delivery of health care around the world. Its accreditation and certification programs are recognized and relied upon by many states as part of their quality oversight activities.
Accreditation can be earned by many types of healthcare organizations including hospitals, doctors' offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. It’s awarded upon successful completion of an on-site survey conducted by a specially trained JC surveyor or team of surveyors who assess an organization’s compliance with JC standards. For most types of organizations, accreditation is a three-year award while laboratory accreditation is a two-year award.
So what happens during the on-site survey?
The surveyor assesses compliance with Joint Commission standards, and the survey length depends on information supplied on the certification application. The agenda includes key activities like the following:
One unique aspect of the on-site survey process is the tracer methodology. This is an assessment of compliance with JC standards by observing the care and treatment provided to patients. In other words, it traces their actual experience. There are two types of tracer activities:
An important step in leading improvement and maintaining accreditation, as outlined by the Joint Commission, is to “go to the gemba.”
Gemba is a Japanese word that means “the real place” or the “location where value is created.”
Leaders go to the gemba to:
By asking the right questions in gemba and actively listening to the responses, the leader shows their commitment to the improvement process. Gemba walks last between 15 and 30 minutes, and leaders ask the following questions:
Gemba walks and tracer rounds are useful in discovering gaps. Gemba walks are a good tool for discovering how the frontline will be able to answer questions during a survey. Laura Benson and the imaging services team at Emory Saint Joseph’s Hospital do walks within the department and throughout the hospital to get fresh eyes on their areas. Laura prefers to bring a tracer and a policy during the rounds so that the team can ask questions related to how the policy is operationalized for the staff in that area.
“it’s important to do rounds related to readiness and environment of care but also have tracers that relate directly to the care provided in that area to ensure employees can speak to their workflow and processes in a standard way that adheres to the expectations set by the Joint Commission,” explains Laura.
When we have a “finding” we put in a work order to facilities or biomed, or assign a task to someone through the tracer tool. That makes it easy to track when something has been fixed and close the loop. Open workorders are posted regularly on huddle boards through the hospital, to keep an issue from escalating into an official finding during a Joint Commission visit.
During rounds, we also speak with the team to walk them through how to “speak to the plan” for larger improvements that help us to meet a standard if there is a gap that requires more than a quick fix.
A gap Laura and her team found relates to saline bags and the way it was stored. They receive 20 100mL bags inside a larger bag, and the manufacturer states that once the outer pouch is opened, the bags inside are good for up for up to 30 days.
The smaller bags are already being used in time, but it was helpful for the team to learn that was the case. After trying different solutions, they decided to start putting stickers with the date on each smaller bag once the outer pouch was opened.
“When you start caring about compliance and tying it to patient and staff safety, it can quickly become a habit,” says Laura. “The Joint Commission is not a big mean machine to make our work lives harder, they are our partner to deliver high quality, safe and consistent care to our patients. The standards and tracers developed from them are a great resource to ensure we are doing the right thing, not just for the survey, but for the delivery of care. Using tracers and incorporating them into Leader Standard Work and daily assignments through DMS are a great way to keep a pulse of the department.”
The Joint Commission (JC) is a not-for-profit accrediting organization globally recognized for offering unbiased assessments of quality achievement in patient care and safety. Its helped hospitals transform their practices by meeting rigorous performance standards for nearly 70 years. JC works with tens of thousands of organizations, giving powerful perspective into the delivery of health care around the world. Its accreditation and certification programs are recognized and relied upon by many states as part of their quality oversight activities.
Accreditation can be earned by many types of healthcare organizations including hospitals, doctors' offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. It’s awarded upon successful completion of an on-site survey conducted by a specially trained JC surveyor or team of surveyors who assess an organization’s compliance with JC standards. For most types of organizations, accreditation is a three-year award while laboratory accreditation is a two-year award.
So what happens during the on-site survey?
The surveyor assesses compliance with Joint Commission standards, and the survey length depends on information supplied on the certification application. The agenda includes key activities like the following:
- A survey-planning session;
- An opening conference and orientation to the organization between the surveyor(s) and the organizations team;
- A dedicated leadership session;
- A competence assessment process;
- An Environment of Care session, including a building tour; and
- An exit conference for the survey team to present a written summary of their findings.
One unique aspect of the on-site survey process is the tracer methodology. This is an assessment of compliance with JC standards by observing the care and treatment provided to patients. In other words, it traces their actual experience. There are two types of tracer activities:
- Individual tracers follow the care experience.
- System tracers evaluate how the organization integrates related processes and coordinates communication among programs/services. This process includes deep discussion and education on the use of data in performance improvement and other topics important to the organization.
An important step in leading improvement and maintaining accreditation, as outlined by the Joint Commission, is to “go to the gemba.”
Gemba is a Japanese word that means “the real place” or the “location where value is created.”
Leaders go to the gemba to:
- To understand the current state by seeing the work firsthand;
- To see the waste and frustration that pulls the frontline away from valuable work;
- Where the truth is found; and
- To support the frontline and build engagement.
By asking the right questions in gemba and actively listening to the responses, the leader shows their commitment to the improvement process. Gemba walks last between 15 and 30 minutes, and leaders ask the following questions:
- Is there standard work? Can you show me?
- Are we following standard work? How can you tell?
- Can the standard work be improved? Who is working on what improvement?
- How can I help you? What roadblocks can I remove?
Gemba walks and tracer rounds are useful in discovering gaps. Gemba walks are a good tool for discovering how the frontline will be able to answer questions during a survey. Laura Benson and the imaging services team at Emory Saint Joseph’s Hospital do walks within the department and throughout the hospital to get fresh eyes on their areas. Laura prefers to bring a tracer and a policy during the rounds so that the team can ask questions related to how the policy is operationalized for the staff in that area.
“it’s important to do rounds related to readiness and environment of care but also have tracers that relate directly to the care provided in that area to ensure employees can speak to their workflow and processes in a standard way that adheres to the expectations set by the Joint Commission,” explains Laura.
When we have a “finding” we put in a work order to facilities or biomed, or assign a task to someone through the tracer tool. That makes it easy to track when something has been fixed and close the loop. Open workorders are posted regularly on huddle boards through the hospital, to keep an issue from escalating into an official finding during a Joint Commission visit.
During rounds, we also speak with the team to walk them through how to “speak to the plan” for larger improvements that help us to meet a standard if there is a gap that requires more than a quick fix.
A gap Laura and her team found relates to saline bags and the way it was stored. They receive 20 100mL bags inside a larger bag, and the manufacturer states that once the outer pouch is opened, the bags inside are good for up for up to 30 days.
The smaller bags are already being used in time, but it was helpful for the team to learn that was the case. After trying different solutions, they decided to start putting stickers with the date on each smaller bag once the outer pouch was opened.
“When you start caring about compliance and tying it to patient and staff safety, it can quickly become a habit,” says Laura. “The Joint Commission is not a big mean machine to make our work lives harder, they are our partner to deliver high quality, safe and consistent care to our patients. The standards and tracers developed from them are a great resource to ensure we are doing the right thing, not just for the survey, but for the delivery of care. Using tracers and incorporating them into Leader Standard Work and daily assignments through DMS are a great way to keep a pulse of the department.”
