Joint Commission readiness

Our Joint Commission survey is expected by December 31, 2010. The Joint Commission performs an intense review of the quality of care we provide to our patients once every three years. The exact survey time is unannounced and the survey usually lasts one week. A team of surveyors essentially consists of three components: nurses who trace the care of a patient from admittance through discharge; life safety experts who focus on the safety of our environment; and a physician surveyor who reviews all aspects of physician performance compared to the Joint Commission standards.

It is absolutely critical that we have a successful survey and receive full accreditation. The survey is the quality report card for our entire organization and is publicly reported. A successful survey is also required to receive funding from Medicare and Medicaid which accounts for 50% of our revenue.

With patient care being our top priority and a spontaneous Joint Commission visit imminent, each one of us must do our best to ensure that every patient is provided high quality care in a safe environment at every encounter while accurately documenting their care. Remember, “not documented, not done”; the care you provide must be properly documented in the patient’s chart to receive credit for your work.

We have organized Joint Commission rounding teams that are surveying all areas. Some teams focus on patient tracers and other teams are focused on the environment. It is time to step it up and get your work areas neat and organized; keep hallways and floors clear of equipment; secure medication carts when not in use; be certain patient care is properly documented in the chart; make sure you know what to do in a fire or other emergency; and follow all infection control procedures (especially washing your hands).

If we all work together we will have a successful survey that we can all be proud of. We will continue to provide updates on the rounding team results in preparation for the survey.