joint commission audit

Stephanie McCoy, BBA, CPCS
Director of Credentialing and Accreditation
January 12, 2017

McCoy Photo headshot square 230px - CopyThe mission of The Joint Commission (TJC) is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” It’s a lofty goal, and one that has helped thousands of healthcare organizations improve.

Unfortunately, the prospect of a TJC review is stressful and overwhelming for many healthcare providers. It doesn’t have to be. Check out these three things we’ve learned by designing and implementing a tested program that ensures that the people of our organization are always prepared to pass a stringent TJC evaluation while also meeting the requirements of our own internal quality programs.

First, keep in mind that patients deserve consistently reliable care. That means healthcare providers must live every day as if The Joint Commission is going to be onsite. Checklists are a great tool for setting expectations for your team. Take care to establish standards based on TJC guidelines, but also include actionable and measurable performance indicators that are unique to your environment. Hold people accountable for the specific behaviors outlined in the checklists. This diligence must be part of your daily routine to ensure consistency and compliance.

Once you have your standards and checklists in place, regularly conduct your own mock audits. Subject your team to the same interview questions and the same level of examination that TJC auditors will use. Don’t cut corners or make it easier than an actual review. In fact, make it harder. The practice will help your team prepare and can identify deficiencies that can be corrected before the real evaluation. These compliance reviews, when conducted with a critical eye, will fuel your continuous improvement cycle.

A truly solid, quality-focused compliance program is absolutely dependent on an organization-wide culture that values adherence and continuous improvement. It’s not just the purview of the compliance office or quality department; everyone must be engaged if your efforts are to succeed. Make sure that your people know what compliance looks like. Talk about it often and emphasize its relationship to your larger goal of high-quality patient care and operational efficiency. Encourage “active observation” by your team members and create a mechanism to report possible violations and suggest improvements.

Our free guide, How to Prepare for a Successful Joint Commission Visit, provides more ideas for making sure that your team is “audit ready.” We, at SpecialtyCare, are proud to have earned TJC certification in Health Care Staffing Services and accreditation in Surgical Ambulatory Healthcare. We appreciate the rigor of The Joint Commission evaluations and approach each visit as a welcome opportunity to have objective, trained experts review our processes and practices. This focus on quality and continuous improvement is part of who we are and serves our larger mission to improve the delivery of healthcare.