YNHH readies for Joint Commission accreditation survey

YNHH expects The Joint Commission (TJC) to arrive unannounced this fall or early winter to conduct its triennial accreditation survey, which measures hospital performance. Over the next several months, Accreditation and Regulatory Affairs will distribute a number of educational and informational tools to help employees prepare for the visit.

Accreditation means the hospital has met or exceeds TJC performance standards and is a nationwide seal of approval.

“Our success will depend upon staff demonstration, articulation and documentation of our safety and quality practices,” said Victoria Dahl Vickers, RN, executive director, Accreditation and Regulatory Affairs. “Crucial to success with regulatory preparedness and surveys are safety and quality practices that become habits in our daily routines and part of how we care for patients.”

This summer, managers will introduce a set of flash cards for use in safety huddles and staff meetings. The cards cover a range of topics TJC surveyors will review with staff when they survey the hospital. The cards will provide questions and answers about topics such as national patient safety goals, life safety and medication management. They will help staff prepare for the survey, as well as reinforce safe practices.

In addition, tip sheets will regularly inform employees about safety matters, providing valuable updates that keep issues top-of-mind. Clinical staff will also receive a small handbook that will fit easily in their pockets for quick reference. This guide contains reminders on many environment-of-care and clinical safety practices, such as fire response and fall prevention strategies.

Non-clinical staff will also receive a pocket-sized brochure for reference. Last month, Accreditation and Regulatory Affairs began holding 30-minute “Lunch and Learn” sessions that cover a wide variety of topics, such as medication management and infection control practices.

“Our goal is to prepare a workforce that is confident and interacts effectively with surveyors,” Dahl Vickers said. “We provide safe, high-quality care and this survey will give us the opportunity to demonstrate the excellent work we do for our patients.”