Crushing the Joint Commission Survey with Teamwork and Confidence!

Purpose: Our facility is a 1,000-bed academic medical center with around 1.5 million outpatient visits annually. This includes ~300,000 visits to community health centers serving low-income populations. Our institution is committed to consistently delivering the safest care possible to every patient. Ensuring excellent performance on The Joint Commission accreditation is a top priority and begins with an “excellence every day” attitude, ongoing evaluation, and continual improvement. Our aim is to improve ambulatory care patients’ care and outcomes and achieve excellent survey results through a multifaceted approach.

Learning objective: Participants will be able to identify strategies to enhance their readiness plans.

Description: Engaging all staff in continuous Joint Commission readiness has proven highly effective. We accomplish this through education, support, and hands-on experiences to encourage teamwork and foster shared responsibility for excellence. We conduct a thorough ongoing risk assessment considering past TJC results, data from other institutions, TJC briefings, NPSGs, new TJC standards, internal mock surveys, safety reporting, and other relevant metrics. A SAFER matrix assesses the scope and likelihood of harm, helps prioritize improvement efforts, and is shared broadly. Effective interdisciplinary tracers are the foundation of readiness. Using an institutionally developed app, tracers identify areas of strength and opportunity, and provide real-time non-punitive feedback and education. Our webinar series led by local experts (It Takes a Team: Promoting Excellence in Ambulatory Care) enhances knowledge about key standards: medication management/safety, teamwork, improving care, diversity, equity, leadership, safeguarding high-risk patients, safe environment, and workplace violence reduction.

Using this knowledge, staff survey their areas using an observation-based EOC weekly checklist to identify and address concerns and empower staff to collectively contribute to maintaining a safe, compliant environment. Keeping leadership informed about checklist results and any barriers identified fosters transparency, accountability, and proactive problem-solving. Highlights of additional resources/activities include: a high-priority leadership checklist for leaders/clinicians; ambulatory care-focused resource webpages including toolkits and webinar recordings; data easily accessible via dashboards; monthly town halls by the compliance department, open to all, sharing results and best practices; distribution of a clinical newsletter to approximately 5,000 ambulatory care employees; executive champions for most challenging standards; and excellence every day committee structure.
Evaluation/outcome: 2021: Webinar attendees reported increased confidence in Joint Commission readiness. Practices’ completion of EOC checklist was associated with a lack of negative survey findings. Excellent results on 2021 TJC survey. 2022: 158 ambulatory care/procedural tracers, with 90% meeting the passing threshold of 75%. 2023: Over 90% of practices surveyed met an increased threshold of 85%. TJC survey in fall.