Nurse Leaders Preparing for Joint Commission Inspections

View all blog posts under Articles | View all blog posts under Doctor of Nursing Practice

Preparation is essential to the best outcomes to Joint Commission inspections and reviews.

Healthcare organizations turn to accreditation agencies — such as the Joint Commission — to demonstrate an organization’s high standards and superior patient care.

As managers, registered nurses (RNs) who have earned doctor of nursing practice (DNP) degrees must be prepared for the rigors of a Joint Commission inspection, including months of planning and unannounced inspections. The Joint Commission, an independent, non-profit organization, accredits more than 80% of the hospitals in the United States.

“Joint Commission accreditation is a signal to patients and providers that your facility takes quality care and patient safety seriously,” said David Dunkelberger,

principal at the internal auditing firm IS Partners LLC. “A facility that has achieved accreditation is one that can be relied on with confidence; accreditation provides prospective patients with unsurpassed peace of mind about their care.”

For nurse leaders, preparation is essential to the best outcomes to Joint Commission inspections and reviews. Duquesne University’s online DNP program educates RNs about what makes an effective nurse manager to tackle Joint Commission audits and other leadership challenges.

Why Pursue Joint Commission Accreditation?

Medical facilities seek Joint Commission accreditation to demonstrate excellence in the field. In some cases, regulatory agencies, insurance companies and managed care contractors require Joint Commission accreditation. The organization also said there are other reasons why should hospitals pursue accreditation:

Validating quality of care

Joint Commission accreditation standards focus on safety and quality of care. Accreditation shows patients the facility has taken extra steps to provide the best possible care.

Bolster quality improvement efforts

Joint Commission standards establish a baseline for improvements for all employees to follow.

Enhance recruitment and education efforts

Accreditation underscores the facility’s dedication to excellence and improvements.

Overall, the Joint Commission uses more than 250 standards to accredit hospitals. These standards address topics that include patient safety, education and rights, medication management, medical-error prevention, infection control and verification of hospital staff credentials.

Accreditation Process

In beginning the accreditation process, medical facilities follow the Joint Commission’s Comprehensive Accreditation Manual for Hospitals (CAMH), which details the standards and policies necessary to meet accreditation requirements.

Medical facilities should organize an interdisciplinary team that will oversee the process, starting with determining where improvements need to be made. After a thorough review of the standards and needed improvements, the team should implement standards compliance into daily work.

During the organizational process, medical facilities should perform hazard vulnerability analyses (HVAs) and risk assessments to determine potential and actual hazards and risks, points of vulnerability and failures and areas for improvement.

Once all the necessary paperwork is in place, Joint Commission surveyors visit the location once every 39 months to evaluate compliance. During the unannounced Joint Commission inspections, called surveys, the reviewers talk to doctors, nurses, other staff members and patients to determine whether the healthcare organization is working to satisfaction. Every three months, the hospital submits public data regarding how specific conditions, such as heart attacks or pneumonia, are treated.

“Joint Commission accreditation does not begin and end with the on-site survey,” the organization said. “It is a continuous process. Every time a nurse double-checks a patient’s identification before administering a medication, every time a surgical team calls a ‘time out’ to verify they agree they’re about to perform the correct procedure, at the correct site, on the correct patient, they live and breathe the accreditation process.”

Nurse Leaders Planning a Successful Joint Commission Inspection

Because Joint Commission inspections are unannounced, nurse leaders who are heading up accreditation efforts must be prepared.  Professional development resources provider Lippincott Solutions said preparing for accreditation requires leaders to compare Joint Commission expectations and standards to an organization’s actual performance.

Lippincott Solutions suggested leaders take these actions for successful Joint Commission inspections:

  • Establish a timeline to prepare for all activities involved in the accreditation process
  • Determine the intent of each standard
  • Identify examples of each standard in action in the workplace
  • Identify areas of partial or non-compliance to standards
  • Assign responsibilities in each standards category to appropriate team members
  • Incorporate standards into daily work
  • Hold frequent educational meetings with staff regarding standards implementation
  • Inform patients about visits from Joint Commission inspectors and possible questions
  • Network with other professionals who have gone through the process

Another essential element of preparation for a Joint Commission accreditation undertaking is meeting quality standards long before they are required. DNP-educated RNs have the skills, training and education to lead a hospital through the process. The online DNP program at Duquesne University provides advanced practice RNs with the instruction needed to lead hospital staffs for Joint Commission accreditation.

About Duquesne University’s Online DNP Program

Since 1935, Duquesne University has been educating nurses to take leading roles in healthcare.  University administrators, professors and staff work to ensure that RNs receive the best DNP education to learn evidence-based skills and practices to improve health outcomes for patients.

The coursework is 100% online, allowing RNs to work toward an advanced degree while maintaining career and family responsibilities. For more information, visit the university’s online DNP program website.




Is Joint Commission Accreditation Right for your Healthcare Brand?:  IS Partners, LLC

Accreditation Guide For Hospitals: Joint Commission

Risk Assessments – Definition and Requirement For Conducting: Joint Commission

Joint Commission FAQ Page: Joint Commission

Preparing for Your Joint Commission Visit: Lippincott Solutions