Are we ready for joint commission

Ensuring that an organization is ready for an accreditation, licensing and/or certification is an on-going process not a one-time activity.

It can be beneficial to utilize tools in order to define the process to ensure compliance with standards and guidelines and to gain commitment from the stakeholders by involving them in the process with specific responsibilities relating to their organizational areas and areas of expertise.

There are two parts to this assignment to prepare a hospital for a Joint Commission Accreditation Survey. Note that although this is for Joint Commission a similar process can be used to prepare for a licensing survey or other accrediting body.

1. Open the document titled "Accreditation Survey Activity Guide for Health Care Organizations" by attach below. Review the document to become familiar with the areas that a hospital would need to assess in order to ensure organization wide readiness for a Joint Commission Accreditation Survey.

For this assignment you will review the section on Leadership and Data Use, page 83.

Based on the information provided in this section of the areas that the surveyor will review with leadership at the time of the survey, create an assessment document that you would have used to perform the organizational assessment for each of the eight areas in the Leadership and Data Use Overview.

Include what information/reports you would have required and from which stakeholders.

This can be done in a table or spreadsheet (see example below). See the list of possible leadership stakeholders below.

2. Open the document title "Checklist for Joint Commission Preparation Readiness" attached below. This document includes a checklist of activities to prepare the organization for survey immediately before the survey team arrives.

Reorganize the checklist in a table or spreadsheet format to identify and assign specific responsibility for each activity, supporting what needs to be done. Utilize the list of leadership positions below and your knowledge of hospital organization. It would be leadership's responsibility to assign the tasks to those Directors under their area of responsibility.

• CEO

• Vice President of Operations (includes all operational areas in the hospital including Environmental, Clinical and Nursing â€" the VP's for these areas report to the VP of Operations

• Vice President of Finance (Director of HIM)

• Vice President of Nursing

• Vice President of Clinical Services

• Vice President of Medical Affairs

• President of the Medical Staff

• Vice President for Performance Improvement

• Vice President of Environmental Affairs

• Senior Director of Risk Management

Requirements

Created a table of topics to be discussed with surveyor. Included the stakeholder, activity for preparation, and outcome

Created a checklist table. Included the responsible leader and what should be done for each activity.

This week we are learning how to get ready for an accreditation survey. This can be a very stressful event for any healthcare facility.

However, the key is not to get ready when you have a survey coming, but to stay ready at all times. In your assignment this week, you are creating tables to help the facility get ready for Joint Commission.

In part 1, you are given an article to read. Go through this article to get an overall feel of what to expect during the survey. Pay particular attention to page 83 as this is the information you will need to complete your first table. On page 83, you are given topics that the surveyor will want to discuss. Your job is to create a table that will include the topics to be discussed, the stakeholder, the activity for preparation, and the outcome. Follow the example table given in the directions.

In part 2, you are given a checklist for Joint Commission Preparations. Go through the checklist and create a table of each preparation activity, the responsible leader, and what should be done for each activity. Your table should look like the example within the assignment directions.