Are You Joint Commission Ready?

 Published: June 6, 2018

By: Heather Willden


image of pen checking boxes from checklist

If the thought of Joint Commission Surveyors showing up at your door sparks anxiety, then these tips are for you. Cheryl Hoerr, MBA, RRT, FAARC, of Phelps County Regional Medical Center, Keith Roberts, MBA, RRT, CPFT, of Rush University Medical Center, and Julie Jackson, BAS, RRT-ACCS, RCP, of UnityPoint Health-Des Moines, share their recommendations on getting prepared and ready for the Joint Commission.

The benefit of being ready

According to their website, the Joint Commission’s mission is to ensure healthcare organizations are “providing safe and effective care of the highest quality and value.”

“When RT departments are focused on meeting the Joint Commission standards they can have confidence that they are doing their best to provide quality care to their patients,” Hoerr said. “When the RT manager knows the standards are being followed consistently and therapists are in a state of perpetual readiness, there is a certain level of peace of mind for the manager. If you are confident that you are in compliance then you don’t have to worry that Joint Commission surveyors may show up on your doorstep the first thing in the morning. You are already doing the right things in the right way!”

Best practice examples

  • The Joint Commission surveyors are laser-focused on infection prevention these days. Respiratory therapists should expect the surveyors to ask a lot of questions about their equipment reprocessing and storage practices. (Hoerr)
  • We established a Standard Work process for each piece of equipment we reprocess. The Standard Work document contains pictures and descriptions of each step in the reprocessing cycle for each specific piece of equipment and is kept in our equipment room for easy reference when therapists are reprocessing equipment. (Hoerr)
  • The department’s policy and procedure manual is another area that can draw unwanted attention from surveyors and lead to requests for improvement. I’ve always tried to keep my policies non-equipment-specific and limit complex details that could result in a request for improvement if a surveyor finds that a therapist isn’t following the policy to the letter. (Hoerr)
  • Compliance with Infection control standards is paramount. Surveyors will review infection control policies to ensure that the content addresses the standards. They will then speak with employees and observe them to ensure that practice matches policy. The surveyor will also be looking for consistency in response and practice between departments. (Roberts)
  • The department must demonstrate to a surveyor that the staff has been trained in all aspects of cleaning and disinfecting equipment and devices. A best practice is to use competency tests. (Roberts)
  • The surveyors want to converse with staff, not managers. Prepare your therapists by rounding up and asking questions a surveyor will likely ask. When a surveyor sees a therapist working with a patient they will ask what their role is. For instance, if working with a ventilator patient they may ask the therapist how orders are carried out. (Roberts)
  • Surveyors are known to check the time of patient admission to an ICU against the time the ventilator was initiated. If the ventilator was started before orders were placed, the surveyor will ask how the therapist determined what settings to use. The hospital may get cited for initiating mechanical ventilation without orders. Unit-based policies and protocols will mitigate this risk. (Roberts)
  • If you are using protocols, the surveyor may want proof that the protocols were approved by the medical staff. This can be done by placing the name of the committee and the approval date on the protocol document and/or maintaining a copy of the minutes. A surveyor will also want to know how competency is demonstrated. Staff must be prepared to describe the protocol, how they were trained, and how their competency is assessed. (Roberts)
  • In our department, we split some of the preparation amongst the leadership. We have leaders within the department that are in charge of orientation, education, employee record management, document control, equipment readiness and emergency preparedness on top of all our normal duties. (Jackson)
  • Everyone on our leadership team, and more importantly, our staff, knows exactly who they need to speak with if there is an issue within one of these areas. These areas are then reviewed throughout the year at our Leadership meetings and with staff periodically at our department meetings. (Jackson)
  • I also try to prepare each year by staying engaged on the AARC Management Community and really watching what other managers are saying surveyors are looking for at their institutions. I believe this helps me to stay up on the latest of what surveyors may be focused on each year since a rule’s interpretation can be so different year to year. (Jackson)


Email with questions or comments, we’d love to hear from you.

Heather Willden

Heather Willden is the Director of Governance and Strategic Initiatives for the AARC where she works with state affiliates as the HOD liaison. She also manages DEI efforts and strategic initiatives. Connect with her about these topics by email, AARConnect or LinkedIn. When she's not working, you can find her podcasting with her husband, exploring new hiking trails, photographing, and spending time with her family.

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