Health & Medical

Please see Attachment to get a better understanding of Assignment.

Class: Health Data Management

Assignment: Are We Ready for Joint Commission

Ensuring that an organization is ready for an accreditation, licensing and/or certification is an on-going process not a one-time activity. It can be beneficial to utilize tools in order to define the process to ensure compliance with standards and guidelines and to gain commitment from the stakeholders by involving them in the process with specific responsibilities relating to their organizational areas and areas of expertise. There are two parts to this assignment to prepare a hospital for a Joint Commission Accreditation Survey. Note that although this is for Joint Commission a similar process can be used to prepare for a licensing survey or other accrediting body.

  1. Open the document titled “Accreditation Survey Activity Guide for Health Care Organizations” by clicking on the link below. Review the document to become familiar with the areas that a hospital would need to assess in order to ensure organization wide readiness for a Joint Commission Accreditation Survey.

For this assignment you will review the section on Leadership and Data Use, page 85.

Based on the information provided in this section of the areas that the surveyor will review with leadership at the time of the survey, create an assessment document that you would have used to perform the organizational assessment for each of the eight areas in the Leadership and Data Use Overview. Include what information/reports you would have required and from which stakeholders. This can be done in a table or spreadsheet (see example below). See the list of possible leadership stakeholders below.



Activity for Preparation


Monitoring Performance of Contracted Services

-Vice President of Operations -VP and Department Directors with Contracted  Services-Legal Counsel-

  • List of all contracted services agreements
  • Identify service provided for which area (Nursing, HIM, etc)
  • Identified performance expectation in agreement
  • Performance monitors in place with timeline and benchmarks

Report on contractor performance and recommendations to continue or cancel.

Accreditation Survey Activity Guide for Health Care Organizations

If the above link will not open by clicking on it, please copy & paste to the hyperlink below into web browser to open.

  1. Open the document title “Checklist for Joint Commission Preparation Readiness” by clicking on the link below. This document includes a checklist of activities to prepare the organization for survey immediately before the survey team arrives. Reorganize the checklist in a table or spreadsheet format to identify and assign specific responsibility for each activity, supporting what needs to be done. Utilize the list of leadership positions below and your knowledge of hospital organization. It would be leadership’s responsibility to assign the tasks to those Directors under their area of responsibility.


Preparation Activity

Responsible Leader

What Needs to Be Done

No patient names are easily visible

Vice President of Nursing (Charge Nurse for each unit and EDVice President of Finance(Director of Admissions and Director of HIM)

Check all patient rooms and nursing stations to be patient names are not visible to visitorsCheck all areas within the department to ensure patient information on screens and paper records is not visible to non-authorized users

Checklist for Joint Commission Preparation Readiness

If the above link will not open by clicking on it, please copy & paste to the hyperlink below into web browser to open.

  • CEO
  • Vice President of Operations (includes all operational areas in the hospital including Environmental, Clinical and Nursing – the VP’s for these areas report to the VP of Operations
  • Vice President of Finance (Director of HIM)
  • Vice President of Nursing
  • Vice President of Clinical Services
  • Vice President of Medical Affairs
  • President of the Medical Staff
  • Vice President for Performance Improvement
  • Vice President of Environmental Affairs
  • Senior Director of Risk Management

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

Save your assignment as a Microsoft Word document.

Tips: Also, this week we are learning how to get ready for an accreditation survey. This can be a very stressful event for any healthcare facility. However, the key is not to get ready when you have a survey coming, but to stay ready at all times. In your assignment this week, you are creating tables to help the facility get ready for Joint Commission.

In part 1, you are given an article to read. Go through this article to get an overall feel of what to expect during the survey. Pay particular attention to page 85 as this is the information you will need to complete your first table. On page 85, you are given topics that the surveyor will want to discuss. Your job is to create a table that will include the topics to be discussed, the stakeholder, the activity for preparation, and the outcome. Follow the example table given in the directions.

In part 2, you are given a checklist for Joint Commission Preparations. Go through the checklist and create a table of each preparation activity, the responsible leader, and what should be done for each activity. Your table should look like the example within the assignment directions.

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