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Librarian's Guide to a Joint Commission Accreditation Survey

The purpose of this guide is to provide answers to questions that librarians might have about the Joint Commission accreditation process as it relates to hospital libraries and information services.

To top of page What is the Joint Commission?

The Joint Commission (JC) is a private-sector, US-based, not-for-profit organization. The Joint Commission operates accreditation programs for a fee to subscriber hospitals and other health care organizations. It accredits over 17,000 health care organizations and programs in the United States. A majority of state governments have come to recognize Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement. Surveys (inspections) typically follow a triennial cycle, with findings made available to the public in an accreditation quality report on the Quality Check website.

All health care organizations, other than laboratories, are subject to a three-year accreditation cycle. With respect to hospital surveys, the organization does not make its findings public. However, it does provide the organization's accreditation decision, the date accreditation was awarded, and any standards cited for improvement. Organizations deemed to be in compliance with all or most of the applicable standards are awarded the decision of "Accreditation."

The unannounced full survey is a key component of the Joint Commission accreditation process. "Unannounced" means the organization does not receive an advance notice of its survey date. The Joint Commission began conducting unannounced surveys on January 1, 2006. Surveys occur eighteen to thirty-nine months after the organization's previous unannounced survey.

Preparing for a Joint Commission survey can be challenging process for health care providers. At a minimum, a hospital must be completely familiar with the current standards; examine current processes, policies, and procedures relative to the standards; and prepare to improve any areas that are currently not in compliance. The hospital must be in compliance with the standards for at least four months prior to the initial survey. The hospital should also be in compliance with applicable standards during the entire period of accreditation, which means that surveyors will look for a full three years of implementation for several standards-related issues.

To top of page What is the Joint Commission's mission?

The mission of the Joint Commission is “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations, and inspiring them to excel in providing safe and effective care of the highest quality and value.”

“Why Health Care Organizations Need A Safety Culture: Achieving High Reliability in Health Care” was the topic of Mark Chassin’s presentation at the 18th Annual Liaison Network Forum held in July 2010 at the Joint Commission headquarters. Chassin was named the Joint Commission’s president in 2009. His presentation’s highlights included the demand by stakeholders for excellence in unprecedented ways, for example, the Dead by Mistake website (www.chron.com/deadbymistake); the need for robust process improvement (RPI); the need to emulate high-reliability organizations, for example, the airline industry; and so on. Chassin announced the Joint Commission’s adoption of RPI and rapid changes to the Joint Commission's culture in order to focus on customers, simplify processes, and reduce costs. RPI is a systemic approach to problem solving proven in many other spheres of work (e.g., lean, six sigma, change acceleration, and so on) and is different from continuous quality improvement (CQI) and total quality management (TQM).

To top of page How is the onsite survey agenda developed?

The onsite survey agenda is developed from the organization’s mid-cycle periodic performance review (PPR) and the priority focus process (PFP).

For the PPR, the health care organization evaluates its own compliance with applicable standards and develops a plan of action for identified areas of noncompliance. Validation of corrections and other randomly selected PPR findings occurs during the triennial onsite survey.

The PFP process aggregates organization-specific information through an automated, rules-based tool. Input information includes ORYX core measure data, previous recommendations, demographic data related to clinical service groups and diagnostic-related groups, complaints, sentinel event information, and MedPar data.

Additionally, the Joint Commission identifies priority focus areas (PFAs) for each hospital based on a combination of the PFP, on which surveyors will focus during the initial part of the onsite survey, and systems and processes that are relevant to patient safety and health care quality. Systems and processes include such things as assessment and care, medication management, credentialing, equipment use, infection control, and so on. Information management is one of the PFAs.

To top of page How does an organization conduct its mid-cycle periodic performance review (PPR)?

  • The organization's Joint Commission team reviews the standards and identifies areas for improvement (fifteen–eighteen-month cycle).
  • The team creates a plan of action for each element of performance (EP) that they have marked as partial or insufficient compliance.
  • The team defines "measures of success," that is, improvement targets with audits. The surveyors will review the measures of success and decide if the targets were met.
  • The team will also conduct phone reviews with the standards interpretation group.

To top of page How will the onsite survey be conducted?

There is a new agenda for the onsite survey:

  • opening conference and orientation
  • survey planning session
  • individual tracer activity
  • system tracer activity (such as medication management, infection control, data use)
  • proficiency testing validation and regulatory review (laboratory only)
  • special issue resolution
  • daily briefing
  • competency assessment process
  • medical staff credentialing and privileging
  • environment of care session
  • life safety code building tour
  • leadership session
  • chief executive officer exit briefing and organization exit conference

It is estimated that 50% to 60% of the survey time will be spent on tracer activities, where the surveyors look at how care is being delivered, rather than on policies. For the "tracer methodology," the surveyors will focus on what is important as identified through the organization's PFP. They will look at how the standards are executed as they follow selected patients through the health care organization. The surveyors will visit patient care settings and functional areas, guided by randomly chosen open records that relate to the PFP information. For example, if the PFP information includes a clinical service group for heart failure, the survey team will trace selected patients from the critical care unit to a medical floor and discharge and look at processes such as assessment and medication management. During the tracer, the surveyors will include all relevant standards.

Videos describing the new process are available. The Joint Commission considers the tracer methodology a way to provide education to the organization staff and leaders.

To top of page What is the scoring process?

Effective with the 2010 Hospital Accreditation Standards (HAS), “EPs are the performance expectations for determining if a standard is in compliance.” EPs are scored on the following three-point scale: 2=satisfactory compliance, 1=partial compliance, 0=insufficient compliance, and NA=not applicable.

Standard IM.01.01.01 relates to information planning

  • “The hospital plans for managing information.”

The rationale for this standard requires that hospitals realize that “planning is the most critical part of the organization’s information management process and requires the collaborative involvement of all levels and areas of the hospital.”

EPs for this standard include “The hospital identifies the internal and external information needed to provide safe, quality care”; “The hospital identifies how data and information enter, flow within, and leave the organization”; “The hospital uses the identified information to guide development of processes to manage information”; and “Staff and licensed independent practitioners, selected by the hospital, participate in the assessment, selection, integration, and use of information management systems for the delivery of care, treatment, and services.”

Standard IM.01.01.03 addresses the need for continuity of

  • “The hospital plans for continuity of its information management processes.”

EPs for this standard include “The hospital has a written plan for managing interruptions to its information process (paper-based, electronic, or a mix of paper-based and electronic)” and “The hospital implements its plan for managing interruptions to information processes to maintain access to information needed for patient care, treatment, and services.”

To top of page What elements of the “Management of Information" chapter are critical for effective management of knowledge-based information (KBI)?

The overview of the chapter discusses why management of information is an essential endeavor:

  • The goal of the information management function is to support decision making to improve patient outcomes…ensure patient safety…[and] improve performance.
  • A hospital's provision of care, treatment, and services is a complex endeavor that is highly dependent on information. This includes information about the science of care, treatment, and services.
  • Managing information is an active, planned activity.

To achieve a vision for effectively and continuously improving information management in health care organizations, the following are critical:

  • ensuring timely and easy access to complete information throughout the organization
  • accessing and using external knowledgebases…to pursue opportunities for improvement

To top of page What standards, rationales, and elements of performance specifically relate to KBI?

The Knowledge-Based Information standard is IM.03.01.01:

  • “Knowledge-based information resources are available, current, and authoritative.”

The Joint Commission defines KBI as “A collection of stored facts, models, and information that can be used for designing and redesigning processes, and for problem solving. In the context of the manual, knowledge-based information is found in the clinical, scientific, and management literature.”

The rationale for the standard delineates the purposes for ready access to KBI for all hospital practitioners and staff. These purposes include maintenance of competence, clinical and management decision making, patient and family information, performance improvement and patient safety, and education and research needs.

The EPs are: “The hospital provides access to knowledge-based information resources 24 hours a day, 7 days a week” and “The hospital makes cooperative or contractual arrangements with another institution(s) to provide knowledge-based information resources that are not available onsite.”

To top of page How will the KBI standards be addressed in the PPR and onsite survey?

The librarian should be an active participant on any management of information planning committee or task force in the hospital. When the PPR is completed, the librarian should be involved in responding to the EPs that address KBI throughout the standards. The librarian is also the professional who can select where and when certain contractual arrangements can be effective (e.g., some consortia agreements are only made between libraries). It is imperative that the librarian emphasizes to administration how this serves the information requirements of the hospital.

The hospital must have backup systems for all types of information, including KBI. The librarian can point out the most effective methods for assuring KBI access when electronic systems are unavailable. A current, organized print collection for basic clinical and drug information, which provides redundancy in case of extended downtime, is the most basic way to address this requirement.

Because the survey team will address all of the standards in some fashion, a hospital staff member may be asked how to retrieve clinical information if the computers are down. KBI may be addressed this way as well. The surveyors will look at how the standards are executed as they follow selected patients through the health care organization or as they do system tracer activities.

To top of page Where else does the Joint Commission address KBI needs?

Throughout the Comprehensive Accreditation Manual for Hospitals (CAMH), the importance of the literature for evidence-based decision making is clearly stated. A few examples are listed below:

  • The “Sentinel Event” chapter states that to be credible, a root cause analysis must include consideration of any relevant literature.
  • Standard MM.08.01.01: “The hospital evaluates the effectiveness of its medication management system."
  • EP 4: “The hospital reviews the literature and other external sources for new technologies and best practices.”
  • EP 5: “Based on analysis of its data, as well as review of the literature for new technologies and best practices, the hospital identifies opportunities for improvement in its medication management system.”
  • Standard IC.01.05.0: “The hospital has an infection prevention and control plan.”
  • EP 1: “When developing infection prevention and control activities, the hospital uses evidence-based national guidelines or in the absence of such guidelines, expert consensus."

Therefore, IM.03.01.01 is not the only place in the CAMH that addresses the importance of KBI in the organization. “Survey time” is not the only time for the librarian to note these requirements. Throughout the year, as the librarian provides services that address these standards, the librarian should point out the contribution of professional library services to these activities.

To top of page How do the MLA "Standards for Hospital Libraries" relate to the Joint Commission standards?

The MLA standards were written to complement and further define the Joint Commission standards. For example, the Joint Commission standards state that information management should be based on the assessed needs of the users. The MLA standards provide a suggested framework from which a needs-assessment process can be developed. In addition to complementing Joint Commission standards, the MLA standards are a useful tool in working with hospital administration and with other accrediting bodies.

The abstract of the MLA standards states, "The standards define the role of the medical librarian and the links between knowledge-based information and other functions such as patient care, patient education, performance improvement, and education. In addition, the standards address the development and implementation of the knowledge-based information needs assessment and plans, the promotion and publicity of the knowledge-based information services, and the physical space and staffing requirements." The MLA "Standards for Hospital Libraries" is a living document that will be added to as the health care environment changes and new challenges present themselves.

To top of page Credits

This overview of the Joint Commission accreditation process is intended to provide some highlights of the ever-changing Joint Commission survey process that may be most useful to hospital librarians. The Joint Commission website provides additional information on the survey process, as well as other critical activities such as national safety patient goals (NSPGs). As MLA members gain experience with the process, changes and additions to the overview will be made. Members are encouraged to contact the MLA Joint Commission member liaison with their ideas and comments. It would also behoove all hospital librarians to purchase the annual CAMH for their libraries’ collections.

Katherine Stemmer Frumento, AHIP
MLA member liaison to Joint Commission, 2006–2012
January 2011

Original text: April 2004 by Margaret Bandy, AHIP, FMLA, MLA member liaison to Joint Commission, 2003–2005, with input from Jeannine Cyr Gluck, AHIP, and Susan Schweinsberg Long, AHIP.

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