Joint Commission Readiness

Donna Sollenberger, EVP & CEO, UTMB Health SystemI was in the process of writing this week’s Friday Flash Report when I received news of an incident that really underscored the importance of always being prepared to spring to action in support of our patients and patient care environments.

During the process of renovating an area on the fifth floor of the John Sealy Annex, a chilled water line broke and caused water to leak through to several areas in the building. Fortunately, UTMB’s Environmental Services and Environment of Care/Utilities Management teams immediately came to the rescue and were able to address and resolve the issue. This is just one example of why always being prepared for unexpected events is so important, and I’d like to give kudos to these teams for their diligence and quick response!

The incident seemed like a perfect introduction to the fact that, although it seems like only yesterday that The Joint Commission (TJC) visited the UTMB campus, nearly 19 months have passed since our last accreditation survey (November 2012), and we are once again in the accreditation survey window.

The unannounced Joint Commission Accreditation survey, which occurs every 18-36 months, is a validation of our organization’s continuous improvement efforts. More importantly, because the accreditation is a nationwide seal of approval that indicates UTMB meets high perfor­mance standards, this is a great opportunity to reinvigorate our current efforts to ensure we are providing the safest possible care for our patients, families and one another.

TJC accreditation can be earned by many types of health care organizations, including hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. The survey process is data-driven, patient-centered and focused on evaluating actual care processes. Surveyors use the tracer methodology by selecting a patient and following the path the patient has taken throughout their hospital stay, observing practices, documentation and the environment, as well as interviewing staff and patients. Surveyors will ask questions about the care each patient received and the steps taken to ensure that it was safe and of high quality.

Areas of focus for the surveyors include both patient-related and organizational functions. Please take a moment to review the brief outline below and be sure to work with your supervisors and colleagues to assure action items in your area are addressed. Our success will require the cooperation and support of every provider and staff member, as well as on everyone’s familiarity with TJC require­ments in their particular area!

The Joint Commission can arrive any time during our survey timeframe. The survey will last five days and your supervisor will keep you informed of survey progress. At the end of the on-site survey, the surveyors will present UTMB with a preliminary report that identifies if there were any standards that were scored as partial or non-compliant, also known as Requirements for Improvement (RFIs).

It is important to note that UTMB’s performance during the survey is made public and available on the Internet. Our competitors, affiliates, referring physicians and – most impor­tantly – our patients and their families will be able to read the details of our performance. However, I prefer to have full confidence in our teams and I believe we will be fully prepared for the survey, because we all share the belief that every UTMB employee at every level is very much responsible for upholding our mission and providing excellent patient care!

For more information on Joint Commission Accreditation preparedness in your area, please visit or contact Janet DuBois, Associate Director of Accreditation. In addition to accreditation participation requirements, the following areas will be considered during The Joint Commission Patient-Centered Accreditation Process:


The patient-focused section includes chapters on Infection Control, Medication Management, Provision of Care, and Rights and Responsibilities.


This section of the CAMH includes chapters on Environment of Care, Emergency Management, Human Resources, Information Management, Leadership, Life Safety, Medical Staff, Nursing, Performance Improvement, and Record of Care.


Identify Patients Correctly

Use at least two ways to identify patients. For example, use the patient’s name and medical record number. This is done to ensure that each patient gets the correct medicine and treatment. It also confirms that the correct patient gets the correct blood when they get a blood transfusion.

Improve Staff Communications

Improve the effectiveness of communication among care­givers (“read back”, timely report of critical values, hand-off communication).

Use Medications Safely

Label all medications before procedures. Reduce the possibility of harm for patients on anticoagulation therapy. Maintain and communicate accurate patient medication information (Medication Reconciliation).

Use Alarms Safely

Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

Prevent Infection

Be vigilant about hand-washing protocol. Use the “proven guidelines” to prevent infection (difficult to treat infec­tions, blood from central lines, after surgery and urinary tract infections caused by catheters).

Identify Patient Safety Risks

Learn which patients are most likely to try and commit self-harm.

Prevent Mistakes in Surgery

Make sure that the correct surgery is done on the cor­rect patient and at the correct place on the patient’s body. Mark the correct place on the patient’s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made. (Take a “time out”).

Thank you for your dedication to delivering excellent care and service to our patients and families!