Preparing for the Joint Commission
Dr. Paul Stefanacci
Chief Medical Officer
As we enter the window for The Joint Commission's unannounced survey, I want to underscore the vital role each of you plays in demonstrating our commitment to delivering exceptional, safe patient care. Your participation during the survey process is not merely a compliance exercise — it is an opportunity to showcase the clinical excellence and dedication that define our medical staff.
Survey Notification and Timeline
When The Joint Commission surveyors arrive, the Medical Staff Office will promptly notify you via email and phone call with details regarding the opening session. The survey will span five days, during which time you may be approached to discuss your clinical practices and patient care processes.
Key Clinical Areas of Focus
I ask that you give particular attention to the following areas, as they represent critical elements of safe, high-quality care:
Clinical Documentation
Documentation excellence reflects our commitment to continuity of care and patient safety. Surveyors will evaluate:
- Timely completion of informed consents and history and physical examinations
- Comprehensive assessments, with heightened scrutiny for patients receiving procedural sedation
- Accurate and complete medication reconciliation
- Properly executed, authenticated orders
- Timely discharge summaries that ensure seamless care transitions
All documentation must include your signature, date, and time of entry.
Universal Protocol and Time Outs
Surveyors will observe our pre-procedure verification processes. I expect full team engagement during all time outs. This means every team member stops, focuses, and actively participates in verifying the correct patient, procedure, and site.
Interdisciplinary Communication
The quality of our patient outcomes depends on effective collaboration. Surveyors may observe physician handoffs, consultations, and team interactions. These observations allow us to demonstrate how we function as an integrated care team, ensuring that critical information flows seamlessly across disciplines and transitions of care.
Protection of Health Information
Our patients entrust us with their most sensitive information. I remind you that protected health information must never be discarded in regular trash cans — always use designated shredding containers. Additionally, ensure that PHI displayed on computer screens is positioned away from public view.
Your Role
You may be asked to articulate how you ensure quality and safety in your daily practice. I encourage you to speak confidently about your clinical decision-making, your engagement with our quality initiatives, and your collaboration with the entire care team.
Thank you for your continued dedication to clinical excellence. Should you have questions as we prepare for this survey, please do not hesitate to reach out to the Medical Staff Office.