04.06 Joint Commission

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  1. Who is The Joint Commission?
    1. Non-profit organization
      1. Accredits and certifies healthcare facilities for meeting certain patient care standards.
      2. Conduct on-site survey’s to determine if a facility can be awarded “The Joint Commission’s Gold Seal of Approval”
        1. Surveys are unannounced and done at least every 3 years.
      3. Establish “National Patient Safety Goals” that tend to guide facilities in their process improvements
  2. What do they do when they visit a healthcare facility?
    1. Follow patient care experience
    2. Assess communication and coordination processes
    3. Check facilities competency assessment process
    4. Check staff credentials
    5. Facility tour – checking environment of care (safety, infection control)
    6. They then decide if there are any “requirements for improvement” (RIF)
      1. If RIF’s are identified
        1. The hospital has time to address these and submit proof of compliance
  3. How does it impact you?
    1. You’ll get a lot of emails!
    2. There will be a buzz in the facility, especially with management.
    3. Be confident about your training
    4. Be prepared to speak if asked a question.
    5. If you don’t know an answer to something consider saying …
      1. “I recently started working here. Let’s go find my mentor and I’m sure she/he can help us find the answer to that question”


Today we’re going to be talking about the Joint Commission. 

Let’s start by just getting an understanding of who the joint commission is.  They are a non-profit organization that offers accreditation and their own “gold seal of approval” to hospitals.  Hospitals want this because it shows the community they are prioritizing patient care and meeting standards. This accreditation is offered after the Joint Commission conducts an onsite survey  These are unannounced and done usually around every 3 years. 

The Joint Commission also publishes something called the National Patient Safety Goals and these generally provide healthcare facilities with a guide for their process improvement. 

What do they do when they come for one of these unannounced surveys?  Well they tend to follow patient care through the facility. They assess processes that are in place for communication and coordination.  They check the hospitals’ competency assessment process- so they are looking at training and skills assessment to see how it’s all done. They check staff credentials and usually take a tour of the facility.  This tends to be the time that nurses are most likely to come into contact with them. They may stop you and ask questions about your orientation or patient care, anything really!

During this process, they are looking to see if the standards are met.  If they aren’t they will identify Requirements for Improvement or RIF’s.  These have to be fixed and addressed before the JC will accredited the facility.

So how does all of this impact you.  Probably not too much actually. You will notice that you get lots of emails about it and you’ll see there are a general buzz and business with management.

Like I said you are most likely to come into contact during the facility tour.  They may stop you and ask questions. Don’t panic or worry! Just be confident in your training and your patient care.  If they ask you something you don’t know, just refer them to your mentor or manager and go find out the answer with them! 

Okay let’s recap.  The Joint Commission is a non-profit organization that accredits hospitals through assessments that take place about every 3 years.  

The process includes and unannounced on-site survey where they look at patient care, processes and take a tour of the facility. 

During this time, your role, is to essentially be honest and be confident. Don’t panic if you don’t know something.  Refer them to your manager or mentor.  

We love you guys! Go out and be your best self today! And as always, Happy Nursing!