Knock-Knock. Who’s There?

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.

Who is the Joint Commission?

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:

• Hospitals
• Surgery centers
• Laboratories
• Home Health Agencies
• Behavioral Health facilities

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.

What is a Joint Commission Visit Like?

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:

• Patient Admission
• Identification, Allergies, Advance Directives
• Medication reconciliation and administration
• Coordinating care with other disciplines
• Patient education
• Preventing falls and infections
• Preventing surgical/procedural errors

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.

What to Do When They’re Coming

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.”

JC Questions Cheat Sheet

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.

1. Do you have a high-alert list, and can users easily access it?
2. Where are the Safety Data Sheets (SDSs)?
3. What tools for pain assessment do nurses use, and when do you reassess pain?
4. How are patient allergies noted and communicated to others?
5. How are critical results handled?
6. How are medications given? Do you override the computer?  
7. Do you scan meds in the hallway or away from the patient?
8. What tools do nurses use to screen for abuse or suicide/self-harm risk?
9. How do you document patient teaching?
10. Where are fire extinguishers located, and what are RACE and PASS?
11. Do you leave charts open on the Computers on Wheels (COWs)?
12. What are your unit-specific improvement plans?
13. What is the procedure for verifying patient identity for blood transfusion?
14. Who performs point of care testing? How is competency met?
15. How long are glucometer strips good for?
16. How do you know the machines are functioning properly?
17. How do you prevent infection when you are (fill in nursing procedure here)?
18. What type of isolation precautions do you use for patients with (insert diagnosis here)?
19. Where are staff permitted to have food and drink on patient care units?
20. What are the hospital-approved disinfectants, and how long should they remain wet?
21. What do you do if this device malfunctions or fails?
22. What do you do if there is a chemo spill on the unit?
23. Where are the oxygen shutoff valves? When would you turn off the supply?
24. Where are your fire extinguishers?
25. How long can patient food remain in the refrigerator?

Summary

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.