Six ways to instantly look better (and safer) for the Joint Commission

Hospital Safety Insider, November 5, 2015

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If you work in a Joint Commission-accredited facility, there's no doubt you try to impress Joint Commission surveyors every time they walk through your doors to inspect your hospital.

Like any assessment, the survey is designed to catch mistakes, to help you fix errors, and to make things safer for your workers and ultimately, the care of your patients.

What can you do to help improve your performance in the eyes of The Joint Commission? After all, the reason your hospital pays them thousands of dollars a year is to have them come in to your hospital and tell you what you're doing wrong. Wouldn't it be nice, if instead, they praised you for all the things you are doing right?

Officials for The Joint Commission gave rare insight into how hospitals can meet the requirements of the Performance Improvement (PI) standards during a session of the American Society of Hospital Engineers (ASHE) annual convention in Boston, Massachusetts in July.

Here are some suggestions for improvement straight from their mouths:

Get out and about. It cannot be stressed enough how important it is for you to get out and know the staff in the different departments in your hospital. If you expect your staff to help you run a safer ship, they need to know who you are. Too many times, employees complain that they know who the CEO of their facility is, but the safety professional is known as the person who hangs out in the basement and holds safety meetings once in a while. The successful safety professional is proactive, and makes it a job requirement to make rounds every day, taking note of the different safety issues that inevitably pop up by just getting out and observing the environment.

Be proactive about what you find.
You will inevitably find things wrong during your daily rounds. A fire door will be propped open, a contractor will have left a can of spray paint on a cabinet, or a printer will be left in front of an oxygen shutoff valve. Whatever you find should be dealt with immediately. If you wait until later to deal with it, you may forget about it, and that will be the day the surveyors come and find it, and write you up for it. Remember that The Joint Commission wants you to be aware of the safety hazards that exist in your facility. Not every hazard can be dealt with right away, but if you take note of the things that need to be fixed, and at least make a plan to deal with it, it shows initiative. If a surveyor spots a problem (e.g., your fire doors don't close properly), and you show the surveyor an existing plan to fix it within a certain time frame, you're likely to escape with a waiver instead of a violation.

Use the standards to set a goal.
The Joint Commission, by establishing standards that its surveyors look for when they survey hospitals, practically gives you a script to follow to help you make your hospital safer. Life safety is a major area that surveyors spend time with, so if your fire doors don't close, you need to focus efforts on that. If you know surveyors will look for improvement in the area of infection control, why not make that your focus? Establish a task force consisting of some of your epidemiologists, infection preventionists, physicians, and nurses, and identify your biggest problems. Then, make goals and take baby steps to reach them. These are the things that will impress a surveyor and establish you as a facility that is focused on improvement.

Be the cheerleader. Improving performance has to be something you believe in, or it won't happen down the line. If your goal is to make things safer, post signs in the break room, develop staff liaisons, and reward staff for little things that help you reach your goals.

Keep impeccable records
. Of course, it's one thing to say you want to get better, but if you don't have a plan in place, and documents that show the process as it happens, no one is going to believe you. That's why experts say that as a safety professional, you need to document everything, make copies, and keep them within easy reach should a surveyor ask for them.
Did you hold a meeting with your task force to identify areas that need improvement? Make sure you have an agenda and attendance records available, as well as a signed record of people who were there. Did you fix the fire doors that don't close properly? Where are the receipts for the new equipment that was installed, and the contracts for the workers that performed the work? Always have a paper trail.

Take tips from your colleagues.
There's nothing better than taking tips from your successful counterparts to find out what you can do to make your facility better. If another hospital had success with a program designed to reduce worker injuries, or reduce infections, or to eliminate unnecessary alarms in the patient wards, you should make note of what it did. In this age of electronic networking, social media makes it easy to connect with your colleagues. The Joint Commission in July announced a collaboration with ASHE to create an online portal that provides online resources and tools for hospitals to be compliant with the eight most challenging Joint Commission Life Safety (LS) and Environment of Care (EC) standards. Check out the portal at for more information.

This is an excerpt from the monthly hospital safety resource Briefings on Hospital Safety. Subscribers can read the rest of the article here. Non-subscribers can find out more about the journal, its benefits, and how to subscribe by clicking here.

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