Joint Commission is coming: Tips for surviving (and passing) your inspection

But with some preparation, you can turn your stress into action, making it more likely for you and your organization to pass with flying colors.

TJC on-site surveys occur at least once every three years. In many cases, there’s no notice of a pending inspection — instead, you’ll get a call from administration letting you know the inspectors are on the way to your floor. In some cases, the Joint Commission notifies organizations of upcoming surveys. But even then, it’s only a seven-day notice. Not enough time to get your ducks in a row if they weren’t there already.

The Joint Commission conducts inspections with two main objectives:

• To evaluate the healthcare organization using TJC performance measures and standards
• To educate and guide the organization’s staff in “good practices” to help improve the organization’s performance

Inspections are performed in sync with normal daily operations on your unit. Instead of focusing just on paperwork, TJC inspectors also scrutinize the delivery of care, treatments, and other services provided by staff.

Prep for your Joint Commission survey

The key to a successful survey is not waiting until the last moment to address any issues occurring on your unit. Being proactive by identifying areas needing improvement allows you to address critical issues which could jeopardize your success. You should be familiar with Joint Commission standards and survey criteria before your inspection so that you’ll know exactly what the inspectors are looking for.

Remembering simple tips (and using a little common sense) are essential for passing your inspection. To make it more likely you’ll pass, remember these preparation tricks:

• Identify practice areas with partial or no compliance with TJC standards
• Plan to achieve compliance in these practice areas
• Implement the plan, evaluating the results and incorporating them into everyday work
• Educate your staff on Joint Commission standards and expectations
• Keep at least one year’s worth of evidence
• Network with other nurse leaders who have experience with on-site surveys

For many organizations, mock surveys are a great way to assess your readiness for the real thing. Mock surveys can incorporate typical on-site survey activities to familiarize your staff with the process and identify areas in need of improvement.

During a mock survey, consider hosting the following activities to help your staff prepare:

• Hold an orientation session. During this time, address any concerns your staff may have and ask them to tell you more about the structure of your organization and how it operates.
• Identify several patients to follow during the mock inspection. This allows you to evaluate individual nurses’ work and adherence to organizational standards.
• Meet with individual nurses to discuss the systems and processes the organization uses to adhere to TJC standards. These may include topics such as data management, infection control, environment of care, medication management, competence, and billing and regulatory review.
• Share your results with your staff. You can’t implement change if the nurses on your unit don’t know what needs to be fixed.

Just remember, the Joint Commission’s mission is to increase the quality of patient care by elevating standards and delivery systems in hospitals nationwide. An inspection isn’t personal, but it is an opportunity to learn about areas that could be improved to enhance the patient experience. With preparation and knowledge, you can make a TJC inspection a positive event.