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5 Factors That Could Influence Your TJC Hospital Accreditation

TJC Compliance

We scoured The Joint Commission's (formerly JCAHO, ) 2014 Hospital Accreditation Standards, and came away with 5 tidbits you might have overlooked, but may impact your compliance and accreditation.*

1. Leadership

Standard LD.02.03.01

“Hospital establishes time frames for the discussion of issues that affect the hospital and the population it serves."

A lack of streamlined communication between hospital leaders on issues of safety and quality is a huge problem in and of itself, which TJC realizes, and looks for during auditing. But, you not only need to prove that the means of communication are present, but that communication on quality and safety is regularly happening between leadership in an organized, respectful fashion. How? By creating time frames (meetings) to discuss patient's and other issues that the hospital has come across. You've read it a million times, from 2nd grade until now, but communication is key.

2. Life Safety

Standard LS.03.01.70

"The hospital prohibits all combustible decorations that are not flame retardant."

With the holidays over, this may not be at the top of your mind, but don't forget it when your auditor/accreditation reviewer shows up. Everyone likes to get into the holiday spirit, but . . . be sure you don’t buy flammable decorations, and even worse put them in problem spots. Oh, and especially don't put them near any space heaters or fuel-fired heaters.

3. Medication Management

Standard MM.03.01.01, Part 18

"The hospital periodically inspects all medication storage areas."

Standard MM.01.01.01 is all about managing medicine safely.  This means doing the once-over every now and then, cleaning the storage areas, ensuring the storage areas have been validated and verified, and monitoring your medical environment over time.  The biggest key however, with most TJC stuff, is documentation. Document every time you check storage areas. You want hard evidence, you want proof. To use data loggers as an example (It's what we are most familiar with, obviously) you should get a device that stores data over time, and allows you to present that data to TJC inspectors, or the QA Manager of the medication at any time.

4. National and Patient Safety Goals

Goal 6, NPSG.06.01.01

"Improve the safety of clinical alarm systems."

The issue of lack of alarms verse desensitized staff has been a hot topic of late, and the TJC has tried to tackle it in this standard. Striking a balance is somewhat obvious, but doing that is another story, and proving you is another story as well. What the TJC offers for advice is this: "Develop a systematic, coordinated approach." They stress the significance of managing scrupulously those alarm systems that are in most direct contact with patients, or have the largest effect on them.

5. Patient Care, Treatment, and Services

Standard PC.01.02.13

"The hospital assess the needs of patients who receive treatment for emotional and behavioral disorders.

We highly encourage you to take a look at all the "Elements of Performance" that the TJC outlines in this standard. They differ for those patients who are being treated for emotional disorders and behavioral disorders, and what is expected out of an assessment can be pretty in depth. PC-12. That's the page, take a look at it and make sure you've taken all the necessary measures when it comes to patient mental health.

Think we missed something? Got a question? Leave a comment below. We'd love to hear from you.

*This post was based on original research done at Dickson. The post should not be used in place of official Standards from The Joint Commission. If you have any questions about the Standards and Accreditation Process, visit The Joint Commission's website at