By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
    Health
    Healthcare organizations are operating on slimmer profit margins than ever. One report in August showed that they are even lower than the beginning of the…
    Show More
    Top News
    healthcare cybersecurity
    4 Helpful Tips on How to Protect Your Medical Practice Against Cyber Attacks
    October 24, 2021
    Health Check Diagnosis Medical Condition Analysis Concept
    6 Health Woes With Online Remedies
    January 19, 2022
    Eight Things Men Should Know About the Male Menopause
    Eight Things Men Should Know About the Male Menopause
    April 24, 2022
    Latest News
    Beyond Nutrition: Everyday Foods That Support Whole-Body Health
    June 15, 2025
    The Wide-Ranging Benefits of Magnesium Supplements
    June 11, 2025
    The Best Home Remedies for Migraines
    June 5, 2025
    The Hidden Impact Of Stress On Your Body’s Alignment And Balance
    May 22, 2025
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
    Policy and Law
    Get the latest updates about Insurance policies and Laws in the Healthcare industry for different geographical locations.
    Show More
    Top News
    healthy nursing school habits
    Healthy Habits for Nursing Student Nursing School Students
    May 24, 2024
    High Deductables
    High-Deductible Insurance and Rising Bad Debt
    July 24, 2015
    How People Are Taking Advantage of Health Deals in the Recent Recession
    February 5, 2021
    Latest News
    Top HIPAA-Compliant Messaging Apps for Healthcare Teams
    June 25, 2025
    When Healthcare Ends, the Legal Process Begins: What Families Should Know About Probate and Medical Estates
    June 20, 2025
    Preventing Contamination In Healthcare Facilities Starts With Hygiene
    June 15, 2025
    Strengthening Healthcare Systems Through Clinical and Administrative Career Development
    June 13, 2025
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: Your 2015 Checklist for The Joint Commission (TJC)
Share
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Business > Hospital Administration > Your 2015 Checklist for The Joint Commission (TJC)
BusinessHospital AdministrationPolicy & Law

Your 2015 Checklist for The Joint Commission (TJC)

Abby Norman
Last updated: January 13, 2015 9:00 am
Abby Norman
Share
6 Min Read
The Benefits of TJC Accreditation
SHARE

The Benefits of TJC AccreditationThe Joint Commission’s review (TJC) is one of the most stressful times for any hospital. You never know the exact day that they’ll show up, but you’ll have a ballpark.

Contents
Getting The Word OutHave Documents/Reports Ready To GoDo Your ResearchMake a List – and Follow ItKnow The National Patient Safety Goals Get an Ethics Check-Up

The Benefits of TJC AccreditationThe Joint Commission’s review (TJC) is one of the most stressful times for any hospital. You never know the exact day that they’ll show up, but you’ll have a ballpark. You’ll have plenty of time to prepare for the visit, but where do you even start when you have piles of literature to review on the goals, benchmarks and ever-evolving standards? In general, there are some aspects of accreditation preparation that are the same year to year – and represent best practices that will keep your hospital operation ship shape year-round. 

Getting The Word Out

If you’re seeking accreditation for the first time, remember that it’s your organization’s responsibility to notify the public, multiple times, that you are undergoing evaluation and they can, at any time, report complaints. If you’re undergoing your annual review, you’ll want to at least notify staff internally when you have an estimated date of review from TJC. Certainly if TJC is coming in response to a sentinel event, you’ll want to be sure that any departments involved have thoroughly reviewed the event, their processes and response.

Have Documents/Reports Ready To Go

You can speed up the process and reduce disruptions to staff’s activities by having all the documentation and reporting that TJC requires prepared and ready to hand over before they’ve even set foot on your hospital’s campus. What will they be looking for? Performance improvement data, infection prevention protocols, your mission statement, an organizational chart that displays the hierarchy, a comprehensive list of departments and chairs, a current inpatient roster (if applicable) and don’t forget the simplest: a map!

More Read

Health Care Buzz Today
Not One War on Cancer, Millions
The Value of Healthcare Portals for Patient Engagement
“A Chronicle of Hope and Promise”: Observations from Recent Journal Issues on PEPFAR
The Benefits of Having an E-newsletter for Your Hospital

Do Your Research

The easiest thing you can do before TJC even arrives is get a current copy of the Comprehensive Accreditation Manual for Hospitals (CAMH) and review it. Using it as a guide, you can figure out who within your organization will be the point person for each department as you plan for TJC’s arrival. Then, on the day of the review, everyone will have clear expectations and actionable steps that they can take to make sure the day is as hassle free as possible.

Make a List – and Follow It

A good list to start with?

  1. Check that you’re in compliance with the National Patient Safety Standards
  2. Look at your most high-risk process and evaluate it
  3. Make sure you have a completed Statement of Conditions
  4. Engage in a thorough self-assessment looking back at areas of weakness you’ve dealt with in the past. Make sure that they’re up to snuff.
  5. Utilize analytics to try to find potential areas of criticism and circumvent it by taking early action when possible. Or, if you won’t have time to make the changes, create a plan which you can present with the intent.
  6. Make sure that each department head knows exactly what they need to review. The head of the kitchen needs to have just as thorough of a checklist and plan as the CMO.
  7. Assume that they will select a complex, high-risk patient as a “tracer” and do your own internal tracing of such a patient so you can catch procedural problems before TJC arrives
  8. Educate your staff about how to answer questions posed by TJC reviewers. Remind them that if they don’t know the answer, they should never make an answer up. It’s okay to say, “I don’t know, but I can find someone who does.”
  9. Make sure everyone is clear on your organization’s mission statement
  10. It might seem simple, but make sure that everyone knows where the closest fire extinguisher is, and, the exit route in case of a fire. You’d be surprised how many organization’s overlook this!

Know The National Patient Safety Goals 

Which include:

1) improving the accuracy of patient identification through two-step verification processes

2) always striving to improve communication between providers and also, between providers and patients

3) improving medication safety and reconciliation post discharge on a regular, ongoing basis

4) reducing the occurrence and risk of hospital acquired infections and

5) identifying risk on a patient population basis.

Get an Ethics Check-Up

Invite a third-party consultant in who can provide an unbiased glimpse into the moral and ethical belief system that pervades your hospital’s culture. Just because the water is calm on the surface doesn’t mean something darker might not be lurking underneath. Not every healthcare organization is fraught with these practices, but it’s in your best interest to uncover these undesirable subcultures before they become dominant.

As you continue to cross all these to-dos off your list, you’ll probably feel an increased sense of confidence as you rediscover what makes your hospital great and get a head start on addressing areas that need improvement. Both practices are a recipe for increased confidence and a stronger year ahead.

TAGGED:Joint CommissionTJC
Share This Article
Facebook Copy Link Print
Share
By Abby Norman
My name is Abby Norman and I am a healthcare blogger. With over 10 years of experience in the medical field, I have developed a passion for helping others understand the complexities of healthcare.

Stay Connected

1.5kFollowersLike
4.5kFollowersFollow
2.8kFollowersPin
136kSubscribersSubscribe

Latest News

women dental care
What Is a Smile Makeover and How Much Does It Cost?
Dental health
June 30, 2025
HIPAA-Compliant Messaging Apps
Top HIPAA-Compliant Messaging Apps for Healthcare Teams
Global Healthcare Policy & Law Technology
June 25, 2025
recovering from injury
Rebuilding After Injury: Path to Physical and Emotional Recovery
News
June 22, 2025
scientist using microscope
When Healthcare Ends, the Legal Process Begins: What Families Should Know About Probate and Medical Estates
Global Healthcare
June 18, 2025

You Might also Like

SaaS Firm Crowdfunds “People-Focused” Image Sharing

January 25, 2014

How the New Requirements for Pathology Lab Accreditation Benefit You

August 30, 2014
ACA health reform
BusinessHealth ReformHospital AdministrationPolicy & LawPublic Health

Health Reform Beyond the ACA: Are We Inching Towards Consensus?

October 27, 2013

Challenging the Status Quo of Addiction Treatment

July 13, 2016
Subscribe
Subscribe to our newsletter to get our newest articles instantly!
Follow US
© 2008-2025 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Username or Email Address
Password

Lost your password?