In its ever-increasing strategies to assert control over the accreditation survey process, the good folks at CMS have basically instructed the...Read More »
As a nurse, regulatory specialist, and certified executive coach, Rachelle Babin brings a unique perspective to leadership, accreditation, and quality. Her 25 years of healthcare experience spans a variety of settings...
In 2021, the nation’s oldest and largest standard-setting body, The Joint Commission (TJC), celebrated its 70th year of accrediting healthcare organizations. Approximately 90% of accredited hospitals in the U.S. utilize TJC. While there are other accrediting organizations (AO), including Det...
March 16, 2020, marked an unprecedented event in The Joint Commission’s (TJC) history. It was on this day that TJC suspended all survey activity due to the pandemic brought on by COVID-19, a novel coronavirus disease. “The Joint Commission’s decision to suspend regular on-site surveys allowed...
As you develop an ongoing survey readiness program, the tracer methodology is an important element. By replicating tracers in a variety of patient care settings, tracking the findings, and linking them to compliance with elements of performance (EP), you can identify gaps in practice and areas...
As the accreditation process has changed, so too has the role of the survey coordinator. This pivotal position is challenged with ensuring accreditation is top of mind while organizations are juggling competing priorities, staffing challenges, and resource constraints. Unannounced surveys have...
As we described in Chapter 1, the Joint Commission survey team uses the tracer methodology to conduct on-site surveys. This chapter will focus on patient tracers—that is, following the road map of care, treatment, and services provided to patients during their stay in your hospital. Tracing each...
If we think of a patient tracer as a map of the care patients receive during an individual visit (from admission through discharge), we can think of a system tracer as a map of a system or process within the healthcare organization. If you are involved in quality improvement at any level, you...
Remember that the tracer methodology is a very fluid process. As organizational priorities, standards, and systems change, so will your tracer tools—and the process for conducting your tracers. Regardless of the method or tools your organization uses, supporting a culture of patient safety...
One chapter that is frequently overlooked is that of the accreditation participation requirements (APR). However, it is important that the APRs do not become the “forgotten standards.” Organizations seeking accreditation for the first time must demonstrate compliance at the time of initial...
