Ryan holds an MBA, LCSW, and PMP and works in healthcare administration. He has successfully navigated through several TJC surveys.
The Joint Commission is Coming!
If you work in healthcare, you know exactly what that means. I'm here to offer you simple and proven steps to prepare for TJC, so you can pass your survey and get on with your life.
4 Easy Steps to Prepare for The Joint Commission:
1. Start Early; Get Your Resources Together: Line up your people and resources and get started.
2. Make Friends with the Standards Manual: Know what you are audited against.
3. Find Problem Areas and Improve Them: Identify issues and get to work.
4. Prepare Your People: Don't overlook this critical step.
No need to be perfect, but you need to get moving
1. Start Early; Get Your Resources Together
You are always moving toward your next Joint Commission survey. It's unavoidable - every 3 years. You know it is coming, so start getting ready. Starting early will make the biggest difference in how ready you actually are come survey time.
Gather Your Team
Figure out early who is responsible for what. Are managers solely responsible to prepare their own areas? Do they have the support and knowledge to do so? Should a higher-level leader oversee prep activities? Who has the skills to organize the efforts? Who will take point when TJC shows up? etc.
The point here is to treat it like a project. Gather your team and don't let it fall to chance.
Gather Your Information
This can take a while so again, start now. Joint Commission surveyors want to see certain documents and proof of work upon their arrival. Thankfully, they also provide a list as a handy guide. See the TJC Survey Activity Guide and look for the "document list" for your specific accreditation.
Make sure this is assigned to just one or a couple people to gather, organize and store this information where everyone can find it.
2. Make Friends with the Standards Manual
Obtain Your Standards Manual
There are 7 Standards Manuals designed for the different healthcare settings, such as Hospital, Laboratory, Behavioral Health, etc. Know for certain which accreditation you have and get the manual.
Most large organizations have electronic copies in some internal system. The key is to know you have the right manual and precisely how to access it in your setting.
Learn the Structure
The manuals are like onions...they have layers. The manuals have chapters. The chapters have standards. The standards have elements of performance. Your surveyor will audit you to the standards and the elements of performance.
Don't get overwhelmed when you finally look at it directly. It's like staring at the sun, it'll hurt your eyes if you look too long. The sheer number of elements is staggering (between 1,000 and 2,000). Take it in. Let it settle. And start outward in. Manual, then chapters, then standards, then elements of performance.
Get to Know it; Spend some Quality Time
You need to treat it like you're dating it. It's complex and won't reveal itself to you all at once. Schedule some time with it or make it spontaneous. Learn about it. Get to know some important details and remember them. Buy it some gifts...okay too far. But do get to know it some.
3. Find Problem Areas and Improve Them
Identify Problem Areas
If you spend enough time in the Standards Manual, it will tell you where you are weak. Write those down in a list. Then add to it any brainstormed problem areas you and your team can think of. You'll have a big list. It always is, that's okay.
Now you need to organize it (however you choose) and prioritize it top to bottom. Pay special attention to any items that involve safety risks and keep those close to the top. Avoid overthinking this. Just get it good enough.
I suggest this step be done with a team. You need everyone engaged in TJC prep to make it work well.
Do the Improvement Work
Now the fun starts. Every place will do this differently, so here are my top general tips:
- Start with a handful of objectives only - don't spread too thin
- Identify a responsible person for each objective and allow them to assemble a team as needed
- Set completion deadlines with periodic check-ins
- Select leaders based on their ability to execute
- Coordinate people and resources between projects
- Keep the changes as simple as possible
- Avoid pushing too many changes to direct care staff at once (change fatigue is brutal)
- Involve direct care staff in the improvements that affect them
- Celebrate victories - don't let it become just an endless stream of work
4. Prepare Your People
Communicate abundantly about TJC prep. The goal here is to normalize the process and gradually instill the necessary information in everyone's heads until it becomes institutional knowledge. That takes time and a lot of repetition, so plan ahead for this.
By leaders I mean anyone with direct reports or responsibility over an area, function, or process. This group has heightened responsibility for survey success, so they must know more. When the surveyor comes, these leaders will be at their hip so they need to be ready. Teach them how to answer surveyor questions. Teach them how surveyors think. Help them be confident, especially if they are new leaders. Give them time and space to ask questions about the survey and to resolve their concerns. Finally, consider something like a daily TJC tip or weekly TJC prep meeting for several months to get this group ready. Any investment here pays off.
Prepare Your Caregivers
The knowledge required of direct care staff is much different, so your preparation tactics should be different too. Mostly they need to know how to competently perform their specific roles, organizational function and structure, patient care issues, patient rights, the responsibilities of TJC, environmental safety issues, etc. Most of this information should already be in annual mandatory educations, so pulling pieces out as reminders can be very helpful.
Gradually and consistently repeat important points until they become second nature. Avoid the last minute cramming if you can.
Preparing for Joint Commission takes work and many months, but taking a methodical approach sets you up for a successful survey. You and your prep team will also build some organizational change muscles that never leave as you tackle more challenges in the future.