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4 Strategies to Comply with The Joint Commission Standards as a Team

Publish Date: February 12, 2020


Keeping up with the latest Joint Commission requirements is no simple task—whether you are a manager, educator or frontline perioperative nurse.

When a surveyor comes to your perioperative department, everyone needs to be current on Joint Commission requirements. Your practice must be fully established to comply with the requirements, whether you are being asked questions by the surveyor directly or are documenting practices that will be reviewed by a surveyor down the road, according to Patricia Seifert, MSN, RN, CNOR, FAAN, a perioperative nurse who has spent her perioperative nursing career working in a number of different roles, including simultaneous roles as RN-First Assistant and manager.

 Too often, frontline nurses are not asked or don’t feel comfortable speaking up with questions about accreditation requirements or sharing ideas for how to comply, Seifert says.

“When it comes to creating standards based on Joint Commission elements of performance, you need a dynamic process that takes into account different learning styles, roles and practice experience to get the best feedback and participation for compliance,” she advises. “Don’t let generational approaches or practice roles be a barrier to compliance in your unique practice environment.”

Here are four strategies Seifert has found effective for all team members to successfully comply with Joint Commission standards

  1. Know and Share Requirements
    No matter your position, take an active role in understanding and talking about the accreditation requirements you’ll need to meet individually or as a team. Recognize these requirements can change annually and may require subsequent practice updates.

“If you are on the frontline and a practice change is introduced to you, take time to ask why and understand how the change was designed to achieve compliance with a Joint Commission requirement. If you are a leader, make sure you understand the different ways your team members get their information so updates and the rationale for changes don’t slip through the cracks. And always encourage questions,” Seifert suggests.

  1. Reverse Mentor

Experienced nurses should make it a habit to ask novice nurses for their ideas to address a compliance requirement because, while experienced nurses may have the background to understand practice, a novice nurse will often have great ideas for new approaches, such as with communication technology, Seifert says.

As an example, consider the Joint Commission element of performance regarding preoperative education. If you are an experienced nurse, you might offer clinical information that is important to cover. However, as a novice nurse, you might be more familiar with a digital learning modality that can be used to help the patient understand an aspect of home care such as incision hygiene in a timely manner.

“Make sure to involve interdisciplinary perspectives in creating standards,” she adds, “because colleagues beyond the perioperative setting, such as in interventional radiology, may be working on solutions to similar compliance challenges that you can modify for the surgical setting.”

  1. Advocate Evidence-based Research
    Work as a team to identify facility nursing research studies and evidence-based practice projects that address patient needs and interventions to meet those needs. You need to have an established culture of safety in which evidence-based practice is the norm.

For example, if you have an influx of Spanish-speaking patients that require new approaches to preoperative teaching, form an evidence-based practice committee to understand language and cultural needs for this population to better communicate with these patients.

“The chief goal of The Joint Commission is constant improvement and that’s something every member of the perioperative team should embrace,” Seifert acknowledges. “There is a lot more expected of nurses today and nurses can meet this challenge by stepping up to the plate to proactively improve in all aspects of practice.”

Free Resources for Members

Guideline Essentials: Improve your evidence-based practice and be survey-ready with customizable tools such as quick views, competency tools, policies and procedures templates, gap analysis tools, and more.

AORN Comprehensive Surgical Checklist: Download this customizable checklist which includes key safety checks as outlined in the World Health Organization (WHO) Surgical Safety Checklist and The Joint Commission Universal Protocol.

Guideline Implementation: Team Communication (1.8 CHs) Communication breakdowns among health care providers can lead to medical errors and patient harm. Accurate and complete communication about the patient and the patient’s care can contribute to improved efficiency, better patient outcomes, and fewer adverse events.

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