The Joint Commission is a non-profit, third-party organization that works to accredit US healthcare organizations and programs. A Joint Commission accreditation is focused on ensuring patient safety and quality of care, and the Joint Commission’s standards are aligned with the Centers for Medicare and Medicaid Services (CMS). To achieve accreditation, a hospital or healthcare organization must first undergo an accreditation survey.
What is a Joint Commission Survey?
A Joint Commission survey is an evaluation of your healthcare facility’s performance standards. Your organization must first pass an accreditation survey to become accredited. Once accredited, Joint Commission surveyors will visit your health care organization at least once every 36 months to ensure your facility is in compliance with Joint Commission standards. These visits are typically unannounced, which can make them tough to prepare for.
If your facility is expecting a Joint Commission survey or is working hard to stay ahead of your next Joint Commission Survey, here’s what you need to know to prepare, from what you can expect from the survey process, to what you’ll need to provide to maintain compliance.
What Should My Facility Expect from A Joint Commission Survey?
A Joint Commission Survey is a long, rigorous evaluation process that can take anywhere from 2-5 days. As a fire protection and life safety systems provider, the Vanguard Fire & Safety team is very familiar with the building safety portion of the Joint Commission survey, and can help provide some pointers about what you should expect from that portion of the Joint Commission Survey.
What to Expect from a Joint Commission Survey:
- A surveyor’s primary goal is to ensure that every action your staff and organization completes is in compliance with the Joint Commission’s performance standards. This includes both patient care, as well as building safety.
- On the patient care side of performance, surveyors will be evaluating each step of patient care to ensure that doctors, nurses, and other staff are in compliance, and are treating patients safely and effectively.
- On the building safety side, surveyors will be looking for two key things:
- Proper system function. The building and life safety portion of the Joint Commission Survey is focused on ensuring that every component of your fire protection and life safety systems are functioning as intended.
- Documentation. When it comes to your Joint Commission Survey, documentation is one of the most important — and time-consuming — requirements. The Joint Commission will require proof of documentation of each maintenance, inspection, and repair activity, from weekly fire alarm tests to 5-year sprinkler system inspections.
How Can You Prepare for a Joint Commission Survey?
Given that Joint Commission surveys are most often unannounced, many healthcare organizations wonder how it’s possible to prepare. The best way to remain prepared for a Joint Commission Survey is to ensure your facility and staff are always adhering to the Joint Commission’s performance standards in every action from patient care to building maintenance. Beyond that, you can take a few additional steps to make sure your facility has everything on hand in the event of an unannounced Joint Commission Survey:
- Read survey preparation materials from the Joint Commission. The Joint Commission provides a wealth of resources on what to expect and how to prepare for a survey on their site. With resources specific to each department of your healthcare organization, and checklists that walk you through exactly what surveyors are looking for, this is all valuable content to read and pass along to department heads and members of leadership responsible for managing the Survey.
- Ensure proper documentation and organization of documentation. When it comes to your Joint Commission survey, documentation is key. The Joint Commission evaluates your compliance based on how every activity in your hospital or health organization is documented. That’s why documentation is so important, and it’s also why your facility should have a document organization strategy in place that makes it easy to pull the proper documentation, no matter when Joint Commission surveyors arrive.
What is the Joint Commission Looking For in The Life Safety Portion of their Survey?
As a fire protection and life safety system provider, the Vanguard team is most often asked questions regarding the life safety portion of the Joint Commission’s survey. The life safety or building safety component of the survey is focused on ensuring that every element of your building is safe for both patients and staff.
A large portion of the survey is dedicated to assessing the compliance and quality of building and fire safety practices, from preventing fires in your healthcare facility to regularly inspecting your hospital kitchen for fire hazards to practicing fire drills in your hospital, and more. Because this is such a significant portion of your survey, the Joint Commission offers a Building Tour Guidance sheet that outlines key elements that the Life Safety surveyor will assess.
The other key component of the life safety portion of the Joint Commission’s survey is their Life Safety & Environment of Care Document List and Review Tool.
How Vanguard Fire & Security Systems Can Help Your Hospital Prepare for a Joint Commission Survey
One of the most important components of your Joint Commission survey is documentation. The Life Safety surveyor needs to be able to verify that your fire protection and life safety systems are not only functional but have also been inspected and maintained according to their standards.
The Vanguard Fire & Security Systems team works with hospitals and healthcare organizations to not only provide the inspections, testing, and maintenance you need but also all the information you need for proper documentation. Our digital documentation system makes it easy for your team to pull up service records in seconds, ensuring you always have the paperwork and documentation you need to present to your surveyor.
A Joint Commission survey is a stressful time for any healthcare organization or hospital. Working with Vanguard helps remove some of that stress. Our service plans ensure your systems are inspected, tested, and serviced according to Joint Commission standards, and our easy documentation tool makes sure you always have the proof you need to confirm that service is always done in compliance with the Joint Commission’s recommendations. For more information about fire protection and life safety systems, inspection, and repair, contact the team at Vanguard Fire & Security Systems.