Seeking and maintaining Joint Commission accreditation

If you’re in the healthcare industry, you know how important it is to gain and maintain Joint Commission accreditation. The goal of The Joint Commission is to continuously improve the safety and quality of healthcare institutions and the level of service they provide to the public. While accreditation is not mandatory, it is necessary for healthcare facilities and laboratories to remain competitive. Joint Commission accreditation offers the following benefits:

• Better quality recruitment and development for your team
• Supports your organization’s efforts to enforce quality and comply with standards
• Increases recognition by insurers and third parties
• Fulfills regulatory requirements in some states

Earning and maintaining Joint Commission accreditation

Although obtaining accreditation is a rigorous process, you can receive assistance for your organization by applying for the appropriate accreditation at the Joint Commission's website. Each type of institution, health service provider or laboratory is required to meet its own set of standards as laid out by The Joint Commission. For initial accreditation, healthcare organizations need to prove proficiency in several key areas and meet compliance standards. In order to prepare for inspection, it is recommended that organizations conduct an internal audit by either assigning a team of in-house experts or hiring a third-party to identify and remedy any areas that don’t meet compliance standards. An inspector will perform a thorough evaluation of quality and safety processes and report any concerns or areas that could stand in the way of obtaining the accreditation.

Surveys vary depending on the type of organization or laboratory. All surveys follow a basic outline, and during your survey you should expect the following:

• Survey-planning session
• Opening conference and orientation to the organization
• Leadership session
• Tracer methodology to use as the framework for assessing standards compliance
• Competence assessment process
• Medical staff credentialing and privileging (hospitals only)
• Environment of care session
• Exit conference, during which the survey team presents a written summary of the survey findings

Once accreditation is received, it is important to maintain safety and quality standards as outlined by The Joint Commission. To maintain accreditation, inspectors conduct unannounced surveys every three years except in the case of laboratories, where accreditation is only valid for two years.

Your individual inspector may focus on a number of different safety and compliance areas. Our experiences suggest that the following areas are often identified during a typical inspection:

• Safe Cylinder Storage — Cylinders must be in storage racks or chained to wall brackets. See your Authority of Jurisdiction for specific storage volume limitations and proximity to flammables and heat source limitations
• Cylinder Transportation — Small cylinders for transport patients should be maintained in a cart or rack
• Cylinder Segregation — Cylinders must be segregated and storage clearly labeled as either full or empty
• Bulk Oxygen Storage Systems — See your Authority of Jurisdiction for specific installation and backup storage requirements
• Medical Oxygen Piping & Manifold Systems — See your Authority of Jurisdiction for specific requirements for validation and annual inspection

A Team Effort

Earning Joint Commission accreditation for your organization or program is team effort. Michael Craig, Director of Medical Gas Services at Airgas Healthcare, emphasizes the importance of leaning on your vendors for help with accreditation. Chances are your vendors have been asked to address similar issues with other organizations and can help you identify areas of focus and safe storage solutions. Leveraging their experience to help implement solutions to meet and maintain the high quality standards and safety requirements outlined by The Joint Commission will give you more time to focus on what matters most: high-quality patient care.