As the accreditation process has changed, so too has the role of the survey coordinator. This pivotal position is challenged with ensuring accreditation is top of mind while organizations are juggling competing priorities, staffing challenges, and resource constraints. Unannounced surveys have...
As we described in Chapter 1, the Joint Commission survey team uses the tracer methodology to conduct on-site surveys. This chapter will focus on patient tracers—that is, following the road map of care, treatment, and services provided to patients during their stay in your hospital. Tracing each...
If we think of a patient tracer as a map of the care patients receive during an individual visit (from admission through discharge), we can think of a system tracer as a map of a system or process within the healthcare organization. If you are involved in quality improvement at any level, you...
Remember that the tracer methodology is a very fluid process. As organizational priorities, standards, and systems change, so will your tracer tools—and the process for conducting your tracers. Regardless of the method or tools your organization uses, supporting a culture of patient safety...
One chapter that is frequently overlooked is that of the accreditation participation requirements (APR). However, it is important that the APRs do not become the “forgotten standards.” Organizations seeking accreditation for the first time must demonstrate compliance at the time of initial...
National Patient Safety Goals (NPSG) are developed by The Joint Commission (TJC) to create focus on specific patient safety issues impacting healthcare organizations nationally. Working in conjunction with the Patient Safety Advisory Group, TJC establishes evidence-based standards for improving...
Hospitals are on the frontline of emergencies, whether dealing with acts of terror or natural disasters such as fire, floods, and tornadoes. Recent events, including the COVID-19 pandemic, have brought a greater sense of urgency to emergency preparedness. Due to the unpredictability of...
Just as important as the care we provide to our patients is the environment in which it occurs, which is much more than just the space within the walls of the facility. The environment of care (EOC) includes special features that protect patients, visitors, and staff. It includes the equipment...
An organization’s human resources (HR) department is generally the first point of contact for prospective employees. Onboarding, staffing, orientation, licensure, certification, training, and competency are directly connected to an organization’s HR department. Effective healthcare organizations...
The Performance Improvement (PI) chapter might appear small; however, it is receiving more survey attention than in previous years. Organizations focused on continuous improvement recognize that they can only achieve better outcomes if they know where to focus their efforts, and data collection...
