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Achieving Accreditation: 8 Best Practices To Prepare for the Survey

The Gold Seal of Approval® is more than just a reflection of a health system's passion for high-quality care. It indicates an active, ongoing commitment to reviewing processes in a patient-centric way.

Preparing for accreditation ensures a smooth initial survey and paves the way for positive future outcomes.

Let’s explore these eight ways to set up your laboratory for success.

1. Understand accreditation standards

The Joint Commission understands that excellent care often begins in the laboratory. Accreditation surveys evaluate performance based on a list of standards.

The standards developed by The Joint Commission include not only Clinical Laboratory Improvement Amendments (CLIA) but criteria pulled from the Centers for Medicare & Medicaid Services (CMS) and the Occupational Safety and Health Administration (OSHA).

Laboratories that review adherence to The Joint Commission standards before applying for accreditation come into the survey process ahead of the game.

The Joint Commission’s Comprehensive Accreditation Manual for Laboratories and Point of Care Testing (CAMLAB) outlines all the standards specific to laboratory services. The CAMLAB also delivers detailed elements of performance and their rationale for each standard.

2. Connect with your account executive

The Joint Commission recognizes that preparation for the survey can result in many questions along the way.

Dedicated account executives provided by The Joint Commission help laboratories navigate questions and move forward in the process.

Account executives guide facilities on an array of topics including, but not limited to:

  • Application-specific questions
  • Questions about your organization's accreditation process
  • Survey date and schedule

Laboratories that connect early on in the process with their assigned account executive ease the burden on staff and streamline preparation efforts.

3. Utilize Joint Commission Connect

Another integral tool in preparing for a successful Joint Commission survey is access to a personalized extranet site called Joint Commission Connect. Labs receive access to the site after applying for accreditation.

The site contains user-friendly resources organized by categories within the Readiness Roadmap. Information in this toolkit comes in a variety of formats:

  • Documents outlining detailed guidance
  • Webinar recordings on standards
  • Videos about hot topics impacting health systems
  • Checklists that provide quick tips

Joint Commission Connect distills information relevant to accreditation that is specific to the laboratory. The survey provides an efficient way to ensure all aspects of survey preparation are covered.

After a laboratory receives accreditation, Joint Commission Connect remains a valuable resource, providing a convenient way to maintain standards and stay abreast of critical guidance updates.

4. Engage other healthcare providers within the system

Laboratories pursuing accreditation with The Joint Commission are ideally positioned to increase collaboration within their health system.

The Joint Commission standards for hospitals and laboratories overlap. Other healthcare providers familiar with the survey process can guide preparation efforts.

Additionally, while some standards are lab-specific, others require collaboration with other departments.

Reviewing individual standards with other healthcare providers allows a laboratory to employ a thorough, holistic approach to survey preparation. This approach, in turn, keeps the focus on high-quality, safe care throughout a patient's entire experience.

5. Take advantage of the Survey Activity Guide

Joint Commission Connect contains a comprehensive Survey Activity Guide that takes the guesswork out of what the on-site survey entails.

The guide provides detailed insights regarding:

  • Documents and information to have on hand for review
  • Which participants need to be involved
  • The general agenda and timeline of the survey
  • Logistical needs of the surveyors
  • The tracer methods utilized during the survey

Reviewing the Survey Activity Guide provides a systematic way to avoid surprises on the day of the survey.

6. Review annual top standards non compliance data

Once laboratories gain knowledge of accreditation requirements — an essential first step — it’s important to understand common issues other health systems encounter with achieving or maintaining accreditation.

Joint Commission Perspectives, an annual newsletter, releases a yearly Top Standards Noncompliance Data Report. The report provides an at-a-glance view of the most common challenging standards and National Patient Safety Goals (NPSGs) within different programs.

This allows laboratories to drive conversations and preparation efforts efficiently.

7. Get a heads up

Beyond knowing requirements and common pitfalls, health systems benefit from understanding how they can prevent potential safety issues or citations from occurring.

The Joint Commission Heads Up Library is available for such prevention efforts.

The library contains more than 50 reports broken down into programs and specific topics. Topic examples include inspection and maintenance of laboratory equipment and critical lab reporting, to name a few.

Heads Up Reports (HUR) delve into all aspects of the standards identified through annual the Top Standards Noncompliance Data Report.

Each HUR follows the same format:

  • Description of the scope of the issue and its particular safety concerns
  • Review of specific observations that led to the citation
  • Discussion of potential factors contributing to the issue
  • Ways organizations can identify concerns through tracer methods
  • Resources to resolve noncompliance

Understanding these issues and how to prevent them is a game-changer for your laboratory.

8. Select key leaders

The task of achieving accreditation is multifaceted and can feel complicated. The final practice organizations can implement for a successful survey involves selecting a group of key leaders to pull the aspects together.

Members of the group should represent different areas of expertise within the health system, including those with previous Joint Commission accreditation experiences.

Key leaders should meet regularly to review individual laboratory standards, following the practices outlined above. Scheduling frequent follow-up meetings among the leadership allows the group to work through questions that come up along the way.

Set Up For Success

Following these eight practices while preparing for a Joint Commission survey simplifies the process and sets your organization up for success.

Ready to learn more about why laboratories choose The Joint Commission?