Joint Commission Readiness

The Joint Commission (JC), an independent nonprofit, accredits hospitals nationwide. To earn and maintain accreditation, hospitals are visited by a JC on-site team every 18 to 39 months. The survey team reviews the environment of care, conducts on-site observations and interviews, and evaluates compliance with hospital standards related to emergency management, infection prevention and control, leadership, and medication management.

• Verify two patient identifiers before provision of care, treatment or services to reliably identify the individual as the person for whom the service or treatment is intended.

• Practice good hand hygiene and correct use of PPE.
  • Remember that clean hands save lives and hand hygiene is required
    • before and after contact with a patient
    • before and after contact with the patient’s environment
    • after body fluid exposure risk
    • during care or work such as moving from a “dirty task” to a “cleaner task” or before performing an aseptic procedure.
  • Remember, gloves are never a substitute for hand hygiene.

• Ensure accurate patient orders.
  • Authorized prescribers are strongly encouraged to write their own orders.
  • Use of verbal orders should be limited to the extent possible. Verbal orders for medications to be given in practices should only be used when a delay could potentially cause harm to the patient.
  • Only use “per protocol, co-sign required” orders if there is a hospital-approved protocol in place. Departmental protocols must be approved by the Clinical Policy and Record Committee as well as the Medical Policy Committee.
  • The “per protocol, no co-sign required” order mode is rarely acceptable outside of the new follow-up orders for order-based scheduling/patient self-scheduling. It is audited frequently and feedback is directed to practice leadership.

• Complete medication review at every visit and medication reconciliation as required. See the MGH policy on these requirements, updated this February (2021), for details.

• Follow Universal Protocol for every procedure, every time.

• Practice high-level disinfection and sterilization. See the High-Level Disinfection and Sterilization Portal, as well as the flyers Disposable vs. Reusable Equipment and Just Spray It.

• Keep patients at risk for suicide safe. A clinician must perform a suicide risk assessment for any patient who presents concerning emotional/behavioral issues. If the assessment identifies such risk, the clinician must appropriately address the patient’s safety needs. See the Patients at Risk for Suicide: Care of policy and the Ambulatory Checklist for the Care of the Patient at Risk for Suicide and/or Self Harm.

• Ensure your practice meets standards on life support training as outlined in the MGH Ambulatory Medical Emergency Response policy. Please be sure your HR employee files include up-to-date documentation of current Basic Life Support (BLS) training for appropriate personnel. Use this information to ensure coverage at all times of operation.
  • Visit the Knight Center’s American Heart Association events page to view a BLS class schedule and enroll. All MGH nurses may register at no cost for a class. There is a fee for materials.

• Review the environment of care. Do not block access to fire extinguishers, panels, fire alarm pulls, and medical gas shut-off valves.

• Conduct low- and intermediate-level disinfection on “non-critical” equipment and environmental surfaces (see Low Level Disinfection: Know Your Wet Times).

• Inventory/inspect equipment:
  • All equipment must be tagged and barcoded and have a current inspection sticker (see the It Takes Two flyer).
  • Check your equipment regularly and report any broken equipment or overdue inspections to Biomedical Engineering.
  • Complete the inventory and connect with MGH Biomedical Engineering with questions.
  • See Biomedical Engineering’s Medical Equipment Management at MGH: What You Need to Know page for details on equipment compliance.

Note: Practices’ efforts to regularly complete the Excellence Every Day Sweep Survey contributed to the excellent environment of care we were able to demonstrate to the Joint Commission during our 2021 visit. We have retired that version of the survey, and there is currently no sweep survey required.