In healthcare compliance, it’s impossible that you haven’t heard – or been part of – the
stories of what can happen when The Joint Commission comes onsite. Still, knowing how
to be prepared for a visit from The Joint Commission can feel nebulous, scary, and
stressful. This guide will help you understand the purpose of The Joint Commission
and how to handle a visit so that it’s more successful than scary for you and your staff.
What is The Joint Commission?
The Joint Commission focuses on patient safety and quality of care, providing hospital accreditation standards that address everything from patient rights and education, infection control, medication management, and preventing medical errors, to how the hospital validates that its doctors, nurses, and other staff are competent and qualified, how it prepares for emergencies, and how it collects performance data and then uses that data to drive continuous improvement.
The Joint Commission’s focus on high quality care and patient safety aligns with the goals of healthcare organizations, which pursue accreditation for a variety of reasons, including to:
- Strengthen consumer confidence in the quality of care at their organization, which could provide a competitive edge
- Qualify for Medicare and Medicaid certification without undergoing a separate government quality inspection
- Mitigate risk by adopting The Joint Commission’s performance improvement strategies around quality of care and patient safety, which can, in turn, reduce liability insurance costs
- Enhance staff recruitment, retention, and development efforts since Joint Commission accreditation can attract qualified personnel, especially since accredited organizations provide additional opportunities for staff to develop their skills and knowledge
How often can you expect The Joint Commission to swing by?
Joint Commission surveyors visit accredited health care organizations every 18 to 36 months (two years for laboratories)* to evaluate compliance with standards.
These visits, or surveys, are unannounced. During the survey, surveyors randomly select patients and use their medical records as a tracer to follow a patient through their entire stay. These tracers serve as a roadmap to evaluate standards compliance. As surveyors follow a patient’s experience in a healthcare organization, they talk to and observe the doctors, nurses, and other staff who interact with the patient. Surveyors often speak to the patients as well.
Joint Commission accreditation goes much deeper than the onsite survey. It is a continuous process that promotes a culture of excellence. With a focus on ongoing improvements, Joint Commission accreditation is an integral part of a healthcare organization’s operations. Throughout the accreditation cycle, organizations are provided with a self-assessment scoring tool to help monitor their ongoing standards compliance.
5 strategies to ensure your vendor credentialing practices meet Joint Commission standards
1. Identify & validate
Have your coordinator confirm that this really is the validation team by accessing your extranet site on The Joint Commission website. Compare the names and photos of your surveyors online to the people standing in front of you.
2. Be a good host
It’s helpful to keep in mind that the surveyors are your guests. Have your liaison set them up with a secure workspace that has internet connectivity and provide them with water and snacks. Keep them comfortable during their visit.
3. Alert your team
Be sure that everybody in your organization who needs to know is aware that the survey team is there, including all clinical and administrative staff. An orientation session and meeting will take place as soon as the surveyors are set up. This session gives them a chance to meet senior leadership, decision makers, and some physicians.
4. Be prepared to explain who’s onsite and why, and be able to show their relevant credentials
The Joint Commission’s standards that are relevant to vendors, contractors, and other types of non-employee credentialing are the same as those that apply to anyone who is entering a facility. Specifically, accredited healthcare organizations must be prepared to produce data to demonstrate they:
- Are aware of who is entering their facility, why they are there, and what they are doing, down to the individual rep level (EC.02.01.01)
- Have processes and policies in place to ensure that patient rights are respected, including communication, dignity, personal privacy (RI.01.01.01), and privacy of health information (IM.02.01.01)
- Have infection control precautions implemented (IC.02.01.01)
- Address the qualifications (HR.01.0.01) competency (HR.01.06.01) and performance (HR.01.07.01) of any non-employees brought into the organization who have a direct impact on patient care
5. Debrief after
Identify what went well during the visit and what didn’t. This is an opportunity to evaluate where you need to strengthen policies or reporting. The best time to have this discussion is soon after the survey ends so that any necessary changes can be made while the information is still top of mind.
Supporting vendor credentialing compliance with technology
An automated vendor credentialing solution provides easy access to analytics and dashboards that can quickly demonstrate compliance with The Joint Commission’s standards for onsite vendors. Dashboards can help demonstrate to the surveyors that the organization is operating effectively.
In the symplr system, using the Credential Dashboard* provides visibility to each individual access level, what the requirements are, as well as the status for each credential for every vendor rep. All vendor activities are automatically and immediately recorded for quick access to real-time data showing the compliance as it occurs.
The Visit History report gives users complete visibility of credentialing data and compliance status across all credentialed populations. You can quickly drill down to see who has visited the health system and sort based on date, department, name, level, and the purpose behind their visit. This is especially helpful in instances when users need to determine which vendors were onsite and why during a specific time period.
Ultimately, you want to have easy access to reports and dashboards that tell the story of your vendor compliance program so surveyors can easily confirm that your organization is meeting the standards for tracking each vendor’s presence onsite, confirming the protection of patient safety and privacy and proving competency and performance.
Key takeaways to keep your vendor credentialing program aligned with Joint Commission standards
- Keep in mind that The Joint Commission is focused on patient (and staff) safety and that has an impact on how onsite vendors need to be tracked and managed.
- Use vendor credentialing technology tools to help provide the surveyors with the information they need about which vendors are onsite, why they are there, and what credentials they have.
- Remember that Joint Commission accreditation goes beyond the surveys. It’s an opportunity to enhance your healthcare organization’s ongoing improvement efforts focused on delivering high quality patient care.
