The Joint Commission inspires healthcare organizations to provide safe and effective care at the highest quality and value. They make sure healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key to providing safe high-quality care. The Joint Commission’s standard goals are reasonable, achievable and are a surveyable performance of an organization. It utilizes patient’s rights, infection control, medication management, preventing medical errors and verifies the qualifications of staff.
Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 1.000 health care organizations and programs in the United States. They continuously improve health care for the public. They evaluate health care organizations and inspire them to excel in providing safe and effective care to the highest quality and value. The Joint Commission is governed by a 32-member board of commissioners that includes physicians, administrators, nurses, employers, quality experts, a consumer advocate and educators. They employ 1,100 people in this field staff, at its central office in Oakbrook Terrace, Illinois, and have an office in Washington DC.
I have chosen to write this paper on the Joint Commission because I currently work in a laboratory and will be having an inspection at the end of this month. I feel like this would be a great learning experience for myself to learn how we prepare for our inspections.
The Joint Commission is not a mandatory certification. This is strictly a voluntary service. The surveyors visit accredited health care organizations a minimum of once every 39 months, and two years for laboratories, to evaluate standard compliance. This is called a survey. Being accredited by the Joint Commission means that the accredited health care qualifies for deemed statues. Deemed status means that the Centers for Medicare and Medicaid services assumes that the organization meets the conditions of participation if it is currently accredited by one of the approved organizations. This is important in order for them to receive payment for services from Medicare and Medicaid patients. An organization that utilize the Joint Commission improve their quality of patient care. The Joint commission’s standards and emphasis on clinical practice guidelines help organizations establish a consistent approach to care, reducing the risk of error. It also promotes a culture of excellence across the organization. This is a consistent alignment with standards that promotes an environment of continuous improvement in the care of patients.
Joint Commission surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other health care professionals. The Joint Commission is the only health care accrediting that requires its surveyors to be certified. Currently, all regular Joint Commission accreditation surveys are mostly unannounced. During this survey, the surveyors will observe doctors and nurses providing care, and also speak to the patients. The focus is on patient safety and quality of care. The hospital accreditation standards address everything from patient rights to infection control, medication management and preventing medical errors. It also prepares for emergencies and verifies that its doctors, nurses and other staff are qualified and competent.
A key part of the Joint Commission’s survey is the tracer method. The tracer method uses information from the organization to follow the experience of care for a number of patients through the organization’s entire health care delivery process. Tracers allow surveyors to identify performance issues in one or more steps of the process. There are a few different tracer methods. Individual tracers are designed to “trace” the care experience that a patient has. For example, if someone comes into the Emergency Department, they will track them from the time they are triaged, see the provider, if they need labs or x-rays. This is how they can identify issues in one or any of the steps. There is also a system tracer method. This is where an interactive session with a surveyor and staff members in tracing one specific system within the organization. The system tracer evaluates the system, including the integration of related processes and the coordination and communication among disciplines and departments in those processes. The goal of these tracers is to identify risk points and safety concerns within different levels and types of care, treatment or services.
The benefits of being accredited by the Joint commission is to help health care organizations help patients. This strengthens community confidence in the quality and safety of care. This also provides a competitive edge in the marketplace. Continuously education staff, so they are fully prepared throughout the year, not just during the time of the inspection. This makes them diligent and aware what is going on in their hospital.
Once the on-site survey has been completed, the surveyors report the accreditation decision based on the survey findings. There are five categories used to report its decision: Accredited; Accreditation with follow-up survey; Contingent accrediting; preliminary denial of accreditation; and denial of accreditation. Accredited status means the organization has shown compliance with all standards at the time of the survey. Accreditation with follow up survey means the organization was not in compliance with certain standards and will have to undergo another survey within 30 days to 6 months to follow up in order to make sure compliance is completed. Contingent accreditation is given when the organization did not meet all of the Joint Commission’s stands at the time of the survey. Organizations may appeal to this status, hover they will have to show compliance with standards. An accreditation decision of preliminary denial means that the organization is significantly below compliance stands in multiple performance areas. Finally, denial of accreditation means that all appeal procedures have been exhausted and the organization has been denied accreditation through the Joint Commission.
The Joint Commission which voluntarily accredits hospitals serves Naval Medical Center Portsmouth, which is where I am currently working. I chose to interview a few co-workers. The first one is Commander Adriane Gaskins. She has served in the United States Navy for 16 years and has been involved with inspections for most of her career. She is serving as Assistant Laboratory Director, and I chose to talk about her role in the leading and overseeing the laboratory to ensure compliance. I wanted to know what exactly are they looking for? They are looking for quality assurance. They make sure we are up to date on our training records, things are stored properly, and all of our S.O.P.’s are up to date and correct. I also wanted to know how she ensures that the staff is prepared for the Joint Commission. Cmdr. stated “she ensures the staff are educated, not just when we are preparing for an inspection but throughout the year. We do training and go through the Joint Commission survivor kit that is provided on the SharePoint through the internet.” She has also stated that we are continuously prepared due to our C.A.P. inspections so we are ready at all times.” I wanted to know if she ever witnessed some type of discrepancy and how it was fixed. She has never been anywhere where there have been discrepancies, but other areas of the hospital have. The pharmacy is always susceptible to errors due to medications not being properly stored, or something that sounds similar are next to each other. Because we are inspected by C.A.P. the Joint Commission doesn’t seem to come down so hard on the laboratory, but they do make sure we are compliant and staying in standards.
I also chose to interview HM3 Flores, who is currently serving in the Laboratory Supply Department. He has been in the Navy for 4 years. This is his first Joint Commission inspection at this command. His job is to make sure all of the department’s training records are in order. He also needs to have the entire laboratory inventories in order, and easily accessible. He also needs to make sure the receipts for all of the supplies are in date and month order. Ensuring all of the store rooms are complaint with being organized and things not piled up on each other. This task is very challenging and difficult for HM3 Flores. He wants to make sure we pass with flying colors, so he has been working on these jobs, as well as his supply job, delivering all supplies to each department.
Commander Gaskins ensures proper education and training to all of the staff. She is a great asset to the laboratory and I am so thankful she teaches from her previous experiences. From one of the top leaders to one of the bottom hospital corpsman, we are all involved and work as a team to make sure we and continuously staying in standards. This is an ongoing and challenging task for everybody, but as long as everyone works as a team we definitely get the job done.
Accreditation by the Joint Commission is desirable by health organizations because it shows consumers that performance standards are being met. As you can see by everything mentioned above, becoming accredited by the Joint Commission is not a quick and easy process for any organization. Obtaining accreditation through this organization is a public accomplishment that demonstrates a health care organization’s commitment to patient care.