Tips for Your First Visit From The Joint Commission

As you embark on your journey in the health care world, you may encounter visits from surveyors from organizations like The Joint Commission. The Joint Commission is a nonprofit organization dedicated to accrediting and certifying health care organizations and programs in the United States. Personnel from The Joint Commission conduct onsite visits to evaluate compliance with their established standards for health care quality and safety. During these visits, surveyors assess various aspects of the facility, including patient care, safety protocols, and organizational practices. The survey process involves interviews with staff, reviews of documentation, and observations of daily operations to ensure adherence to accreditation requirements. 

During the onsite visits, surveyors from The Joint Commission may ask questions pertaining to various aspects of health care delivery and safety. These questions could include inquiries about patient care protocols, infection control measures, medication management practices, emergency preparedness procedures, staff training and competency, patient rights and privacy policies, and quality improvement initiatives. An example of a question that an OR nurse may be asked is, “How do you know that a tray is sterile; could you show me?” Remember, you know your patients and the care you provide better than anyone else. Take a deep breath and confidently share the amazing work that you do every day. Tell the story of the excellent care you’re providing – your passion and dedication will shine! 

2. Follow Your Facility’s Processes and Policies

Continue to adhere to your facility’s processes and policies during the visit, as you do every day. Consistency is key to maintaining high standards of care. It’s important to not only know and follow safe, quality care standards but to also understand the rationale behind following these policies. Understanding and following care standards helps to meet the expectations of surveyors, who are evaluating the facility for opportunities for improvement. Implementing these guidelines ensures compliance and promotes consistent, high-quality care. 

3. Prepare for Specific Types of Questions 

There is opportunity to “brush up” on your knowledge of key perioperative nursing principles and practices and facility-specific protocols and initiatives. For example, a surveyor may ask about your fire safety protocols. Remember your abbreviations like PASS (Pull, Aim, Squeeze, Sweep) for extinguishing fires and RACE (Rescue, Alarm, Contain, Extinguish) for responding to fire emergencies.   

You also may be asked, “How do you clean a piece of equipment in the OR?” An appropriate response would include using a hospital-approved product and cleaning as indicated by the manufacturer’s guidelines. Also, you may be asked, “Is there anything that you would change in your facility?” A good response to this question would be discussing the process improvement projects that the facility is working on and your involvement and ability to provide feedback if applicable.    

4. Know and Use Your Resources

Nobody expects you to have all the answers. If you’re unsure of the answer to a question, don’t panic; simply seek clarification. Utilize available resources or reach out to your chain of command for assistance with answering the question. Above all else, be truthful in your interactions with surveyors. Transparency builds trust and credibility, which are both essential in health care. If you don’t know the answer, don’t make it up. Instead, state, “When I need help with a process or have a question, I access my resources; can I do that at this time?”  

5. Keep it Professional 

During interactions with surveyors, maintain a professional demeanor. When answering questions, be direct and to the point. Clear communication helps ensure understanding and efficiency. Show respect to surveyors by maintaining eye contact and being fully present during conversations. Acknowledge their presence and expertise – it’s all part of creating a positive impression. 

6. Focus on the Present 

Remember, surveyors are evaluating the current state of affairs at your facility. Focus on what’s in place now rather than dwelling on past issues.  

7. Show How Teamwork Makes the Dream Work

The Joint Commission surveyor will ask to watch the procedural team in the OR. They will examine patient safety processes such as conducting the Universal Protocol (ie, conducting a pre-procedure verification process, marking the procedure site, and performing a time out), discussing the fire risk assessment, and handling and passing medications. Involving the multidisciplinary care team in discussions and responses when appropriate would be beneficial. Collaboration demonstrates a unified approach to patient care and safety. 

8. Be Yourself 

Let the knowledge you have and the preparation you’ve completed instill confidence in your interactions with surveyors and demonstrate readiness for their visit. Your professionalism will shine as you communicate with assurance that you prioritize safe patient care every day. Showcase to surveyors the unique skills and expertise you bring to your department. Confidence and authenticity in your demeanor will create a lasting impression. 

Conclusion 

Facing a visit from The Joint Commission or any surveyor can be an opportunity to showcase the exceptional care and professionalism that you bring to your role as an OR nurse. By following these tips and staying true to yourself, you’ll navigate this experience with ease and leave a lasting impression of excellence. Keep up the fantastic work, and remember, you’ve got this! The checklist in Sidebar 1 serves as a guide to help OR nurses prepare for a successful visit from The Joint Commission or any surveyor—ensuring professionalism, clarity, and adherence to protocols.