It’s Joint Commission. And they’re visiting your facility. If you’re a nurse who has never met the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), then it’s likely you have some questions. You might wonder who the JCAHO inspectors are, what they do, and how to act when they’re around.
If so, you’re in the right place. This nurse’s guide to the Joint Commission (JC) will put your mind at ease. Here’s what you need to know before their next visit.
JCAHO is the organization that certifies and sets the standards for healthcare programs in the US. In 2007, it shortened its name to the Joint Commission (JC). Healthcare companies and institutions implement policies and procedures to meet the JC standards and apply for their accreditation.
Examples of facilities that might seek recognition from the Joint Commission include:
In the US, key federal programs like Medicare and Medicaid require healthcare facilities to be certified by the JC as a condition of payment. In truth, accreditation is voluntary. Still, healthcare facilities largely view it as essential. The JC standards are intended to improve patient care, satisfaction, and outcomes. As a nurse, it is likely you were oriented and trained to many of those standards during your job orientation.
The JC trains healthcare experts, like nurses, doctors, laboratory technologists, and hospital administrators, to perform site inspections at their certified provider and supplier facilities. These on-site visits are called surveys. In other words, the JC surveyors are healthcare professionals, just like you. That means they are concerned about your patients. And they understand the demands healthcare workers face. That should give you some peace of mind.
JC visits its certified organizations at least once every three years. Often there is no warning. On the other hand, sometimes facilities do know in advance. But usually, the notice is short. When the JC inspection begins, surveyors will visit the units, talk to nurses and other staff, and interview patients.
The purpose of the inspection is to see how well an organization is following current standards. During an on-site survey, the JC does this by selecting random patients. Next, it uses the patient’s medical record as a map to trace the patient’s journey through a healthcare facility. These patients or charts are sometimes referred to as “tracers.”
Throughout the tracing, the JC will observe how nurses and other employees handle patients when it comes to:
Surveyors often investigate the treatments and services provided by the staff. They ask plenty of questions. When they interview patients and staff members, nurses may be put on the spot. But don’t worry. Typically, a nurse manager helps guide the JC surveyor around. So you won’t be alone. And it is important to remember that the JC inspector is there to judge your organization. Do not take anything personally when it comes to surveys.
So now you probably want to know what to do when the JC visit is announced. Well, the good news is you are already more prepared than your colleagues because you’re reading this article. But don’t be stingy. Go ahead and share this resource with them. And here are a few more tips.
During a JC visit, one great thing you can do is share a positive patient experience. It doesn’t have to be forced or rehearsed. But if you can think of a great outcome or a patient compliment, then share it! That could positively impact your team, manager, and surveyors.
If you are notified in advance that the JC survey is coming soon, be sure to read the updates from your management team. Announcements and emails will have important information about facility policies, where to find information, or how to perform tasks. Use your resources. Know how to find the policies and procedures. Talk to your manager if you are unsure about something.
The next word of advice is this: keep your eyes peeled. What’s the old saying? Your mom doesn’t work here, so clean up after yourself. Move out-of-place linen carts, machines, or furniture that you. If you see something broken, fix it, or tell someone.
And lastly, if you find out only minutes before or have no warning at all, don’t panic. The number one thing to do when the JC visits your facility is to stay calm. The JC surveyors know the standards, but you know your job. Take your time answering any questions. But be clear and to the point. If you are quizzed about cleaning solutions, and you aren’t sure, say, “I am going to find the answer to that.” And then go find out. Or find your manager. It’s best to avoid saying, “I don’t know.”
When it comes to knowing what to say, here is a list of common questions that JC surveyors ask nurses so you can be ready.
In short, the JC is nothing to fear. Now that you know who they are and what they do, you can relax the next time someone says “JCAHO.”
Do you have a JC visit story to share? If so, put it in the comments below. Or share a tip for survey preparedness. Share this post and subscribe for more like this.
Sarah S. Falcone BSN, RN is a dedicated nurse based in Dallas-Ft. Worth, TX. Her first nursing gig, was night-shift floor nurse in women's services (PP, L&D, nursery). Through a series of fortunate events, she found home health and a passion for helping seniors age in place. Connect with her on LinkedIn.