Joint Commission Essay

Our institution organizational function will be under review. The Joint Commission will survey our patient environment of care, emergency management, human resources, information management, leadership, life safety, medical staff, nursing, performance improvement, and record of care.

Our management of the environment of care looks at how safe, functional environment within the hospital so that quality and safety are preserved. The environment of care is made up of the building or space, including how it is arrange and special features that protect patients, visitors and staff. It also encompasses the equipment used to support patients and the people, including employees, patients and visitors (The Joint Commission, 2013). The environment

We will undergo tracer methology review process to assess standard of compliance. Tracer Methodology utilizes the patient care experience to assess standards compliance. At the beginning of the on-site survey, the surveyor(s) will select patients from the organization’s files. The surveyor(s) will ‘trace’ the patient’s experience, looking at services provided by various care providers and departments within the organization, as well as ‘hand-offs’ between them. This type of review is designed to uncover systems issues, looking at both the individual components of an organization and how the components interact to provide safe, high-quality patient care (The Joint Commission,

If there are no RIF, our organization will be accredited. If, we are given RIF, accreditation will not be awarded until corrected. If given a RIF, we must complete Evidence of Standards Compliance (ESC) to show that the organization is now meeting those standards and elements of performance. The ESC report on corrective actions taken must indicate, by title, one individual ultimately responsible for the corrective action and overall and ongoing compliance. Concisely describe the actions completed to correct each finding (for example, staff training, and policies/procedures developed, revised, approved, and so forth). We must indicate the dates each action was completed to correct each finding. A description how compliance will be sustained with this element of performance (for example, processes policies, procedures, and so forth). Once Joint Commission receives and approves an ESC it will be required to monitor compliance for four months. An explanation of the plan for assessing effectiveness of the corrective action taken and include sample size for audit based on average daily census, monthly visits, and so forth and random sampling method used if our organization is not performing an audit on 100% of the population and