The Joint Commission Survey Readiness
■ Periodic Performance Review Assistance - Our consultants can help you complete your Periodic
Performance Review. Through on- and off-site review, we can assess your degree of compliance, resulting
in accurate scoring of the Joint Commission standards and elements of performance.
■ Mock Survey: Joint Commission Readiness On-Site Assessment – QHR conducts a comprehensive review
of key documents along with an on-site mock survey to determine your hospital’s compliance with the Joint Commission
standards, National Patient Safety Goals, and readiness for an accreditation survey. The readiness assessment
can be unannounced if requested. Within 30 days, you will receive a detailed report identifying noncompliance
and recommending specific action steps needed to achieve compliance.
■ Continuous Joint Commission Survey Readiness Program – QHR experts can help you design and
implement a continuous survey readiness program for your facility that is comprehensive, collaborative, educational,
and consultative, so that your organization can always be in compliance with Joint Commission standards. Our
periodic assessments provide you an accurate and objective reflection of Joint Commission compliance
within your organization at any given time.
■ Joint Commission Focused Services Review – We work with your leaders and staff to assess compliance
with applicable Joint Commission standards for any area of your facility, such as ED, OB, Behavioral Health or
Surgical Services. Our review includes a departmental mock survey, a review of Policy and Procedures, performance
improvement activities, national patient safety goal implementation and medical record documentation.
■ QHR Learning Institute Courses - Through the QHR Learning Institute, we offer both classroom and web-based
Joint Commission education programs. We can also customize education to meet your specific Joint Commission
educational and staff development needs, designing educational content to meet your organization's goals. Ongoing
education programs include:
■ QHR Case Studies - Helping Hospitals Prepare for Surveys
Joint Commission White Paper
For more information on QHR Joint Commission Services, contact:
Pat Cooper, Practice Leader, 800-233-1470 ext. 4775.
Joint Commission Readiness On-Site Assessment – QHR conducts a comprehensive review of key documents along with an on-site mock survey to determine your hospital’s compliance with Joint Commission standards and readiness for an accreditation survey. The assessment can be unannounced, so that only a few know our arrival date. The program includes:
- Assessment of patient-focused and organizational functions
- Performance of patient and system tracer activities utilizing tracer methodology
- Evaluation of patient records and other information systems that support the delivery of quality patient care
- Examination of the organization’s Performance Improvement process including the mechanisms in place to address sentinel and other untoward events
- Review of Competence Assessment Process
- Analysis of the condition of the physical plant, environment of care and, when applicable, the organization’s Statement of Conditions
- Review of the Medical Staff Credentialing / Privileging Process
- Education and consultation with staff, one-on-one and small group, throughout the Readiness Assessment to improve their understanding of Joint Commission survey processes, quality performance and standards
- Evaluation of training needs
- A detailed report to the hospital 30 days following each Readiness Assessment, which outlines findings and recommends specific action steps to achieve Joint Commission compliance
Periodic Performance Review Assistance
Our consultants can help you complete your Periodic Performance Review. Through on- and off-site review, we can assess your degree of compliance, resulting in accurate scoring of the Joint Commission standards and elements of performance. This is accomplished by:
- Reviewing relevant documents / policies / procedures
- Conducting patient tracer activities
- Reviewing Performance Improvement data / analysis
- Determining compliance with the National Patient Safety Goals
- Interviewing staff / team members
We begin by developing a draft agenda and reviewing key documents several weeks prior to an on-site visit, providing sufficient time to modify the site-visit agenda if required. QHR’s Joint Commission consultants can also provide assistance with implementing action plans, developing materials and conducting staff training about the standards and processes including tracer methodology.
Continuous Joint Commission Survey Readiness Program
QHR prepares you for the Joint Commission’s Shared Visions-New Pathways® initiative that requires organizations to demonstrate continuous survey readiness and know how their facility measures up at any given moment.
QHR experts can help you design and implement a continuous survey readiness program for your facility that is comprehensive, collaborative, educational, and consultative to continually maintain compliance with Joint Commission Standards. Our consultants work in collaboration with your staff through periodic on-site and off-site consultation (teleconferences, electronic communication, document review, document preparation) and other activities requested by an organization. Services available include, but are not limited to:
- Assist in creating a cross-functional Joint Commission preparation team with team members from administrative and clinical departments
- Review the accreditation process with the organization’s Joint Commission leader
- Assist with implementing recommendations for improvement
- Provide standards interpretation
- Advise development of documents such as policies, procedures, program descriptions, program evaluations and other documents
- Examine existing documents for standards compliance
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- Review performance measurement indicators
- Conduct education, training and consultation with staff, one-on-one and small group, throughout the Readiness Assessment to improve their understanding of the Joint Commission survey processes, quality performance and standards
- Conduct on-site mock survey reviews on a periodic basis
- Provide periodic feedback to the hospital which outlines findings and recommends specific action steps to maintain Joint Commission compliance
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Joint Commission Focused Services Review – We work with your leaders and staff to assess compliance with applicable Joint Commission standards for any area of your facility, such as ED, OB, Behavioral Health or Surgical Services. In this review, our consultants:
- Perform a detailed Mock Survey of your Department
- Provide education for your staff
- Review and advise in the development of Policy and Procedures
- Evaluate departmental performance improvement activities
- Review National Patient Safety Goal implementation
- Evaluate medical record documentation
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