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11 ways to prepare for the Joint Commission

iStock_000040396600_SmallHealthcare organizations exist in an environment of accountability, and a complexity of deliverables. With outcomes driving reimbursements, patient safety remains a top priority.

Whom is responsible for patient safety? All staff members from Leadership to the front line staff.

The Joint Commission is a governing entity that has oversight for the inspection, education and feedback to a hospital’s current workflow, policies and procedures. They also award accreditation status that impacts a hospital’s standing in their peer community.

In order to prepare for a successful outcome of a surveyor’s visit, here are some practices to create or implement.

  1. Establish a plan with a timeline
  2. Assign responsibilities for each category of standards and activities
  3. Identify existing “examples of evidence” to meet standards
  4. Identify areas of partial or no compliance with standards
  5. Develop a plan to achieve compliance of the identified areas
  6. Implement and evaluate the plan
  7. Incorporate standards into day-to-day work duties
  8. Educate all staff on the standards and ways to meet them
  9. Conduct a mock survey — score all applicable standards
  10. Read JCAHO literature relevant to accreditation status
  11. Network with others who have gone through the accreditation process

Preparation is best managed when a small group of employees are responsible for the process. These individuals must understand and be able to:

  1. Communicate the process and standards to other staff members
  2. Delegate responsibility
  3. Conduct effective meetings
  4. Create lists of needed policies, evidence, and forms
  5. Write internal policies that address JCAHO standards
  6. Create forms that provide evidence of compliance with standards
  7. Visualize the integration of compliance into daily activities
  8. Motivate and build confidence in staff

Successful accreditation processes promote morale and attest to high organizational performance. With this in mind, many healthcare organizations have implemented the utilization of VMS tools to monitor and maintain credentialing for both internal/external clinicians. Vendor management tools such as Shiftwise, enable a hospital to maintain standards, related to compliance, and not compromise patient safety. Long gone are the days of Excel spreadsheets. With an automated system, such as ShiftWise, a Nurse Manager or HR representative can generate reports on credential status, or be alerted to a forthcoming expiration, with the touch of a “click”.

Credentialing is a key component that ensures all staff adhere/meet the standard requirement, prior to performing at the unit/patient level. Automation is the best way to achieve organizational goals, with the highest level of efficiency. Without an integrated solution to track workers’ credentials, organizations are ill-equipped to make the strategic decisions necessary to deploy contingent labor efficiently and safely.

Check out www.shiftwise.com for more information.

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