Five Things to Know About The Joint Commission Accreditation Survey
Surveyors from The Joint Commission (TJC) are expected to visit the Brigham unannounced to conduct BWH’s triennial, hospital-wide accreditation survey any day now. Our goal during the five-day visit is to demonstrate the unwavering commitment we have to our staff, patients and their families, our dedication to upholding the highest standards of quality and safety and our work to ensure that our practices are consistent with the 2022 National Patient Safety Goals.
During the visit, a team of surveyors, made up of physicians, nurses, hospital administrators, a hospital safety engineer and other health care professionals, will be escorted by Brigham staff and visit nearly all parts of the Brigham, including inpatient units, select ambulatory care practices and distributed campus locations.
The Joint Commission uses a patient tracer methodology to follow a patient’s care at the Brigham and to observe how we provide care to our patients. Here are five things that every employee should know about their pending visit:
- All staff should be prepared to interact with surveyors and answer their questions. Staff should remain positive, welcoming and professional when surveyors visit an area and be prepared to discuss both direct or indirect roles in supporting safe patient care and in quality assurance and performance improvement in the department. Please consult your supervisor or manager if you do not know the answer to a surveyor’s question.
- Always wear your hospital ID badge properly, either pinned or clipped to an outer garment, picture side out, right side up, above the waist on the front side of the body. For additional details, please visit PikeNotes.
- Understand your role in emergency preparedness and responding to any type of emergency.
- Ensure that there is no clutter in hallways, elevator lobbies, connecting corridors and storage rooms, and that any food and drink is in an appropriate location. Please make sure that access to emergency equipment (such as fire doors, fire pull stations, fire extinguishers, medical gas shut offs, sprinklers and eye wash stations) is never blocked.
- For patient interactions that involve treatments or procedures, administration of a medication or blood, collecting a specimen or transferring or transporting, remember to always identify using two patient identifiers: name and date of birth or name and medical record number. See more information in the Patient Identification Policy. Remember to always practice hand hygiene before and after every patient interaction.
For many months now, staff from Clinical Compliance, as well as several other teams, have worked to lay the foundation for a successful survey. It is critical that staff continue to do their part to prepare as well because we all play a role in keeping patients safe. For additional details about how we are continually prepare to be ready for every patient, please visit the Continual Readiness page on PikeNotes.