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Joint Commission Survey Readiness: What House Staff Need to Know

Background on Joint Commission

The Joint Commission is a private organization that develops quality and safety standards for health care organizations. Most hospitals in the country seek accreditation by Joint Commission. The Joint Commission establishes standards that all accredited institutions must comply with. These standards involve all aspects of hospital operations and health care delivery including but not limited to patient care, patient rights, documentation, the physical environment, infection control, and credentialing of medical staff and patient safety. The Joint Commission surveys hospitals every 3 years.  Pitt County Memorial Hospital was last surveyed in February 2006.

Unannounced Survey Process

As of January 1, 2006, the Joint Commission triennial surveys are unannounced.  We are scheduled to have a survey within the next 12 months. The Joint Commission continues to randomly survey a small percentage of hospitals each year. Our focus at PCMH is on continuous survey readiness.

Following is a summary of some key hospital policies that are critical to compliance with the Joint Commission standards.


- Do not use abbreviations - see unsafe abbreviations in the grid below in the section on 2008 National Patient Safety Goals.  These abbreviations are not to be used in our hospitals.

- Telephone orders - All telephone orders must be countersigned within 48 hours. The physician must wait for the person taking the order to write it down and read it back (no other verbal orders except in an emergency). Please collaborate with the individual taking the telephone order in this process so the patient gets the safest care possible.

- History and Physicals -- A complete history and physical must be documented and signed within 24 hours of admission. When the H&P has been completed by a resident, the attending physician must countersign within 24 hours of admission.  An update must be written on any H&P written prior to the patient’s admission. The signed H&P must be on the chart prior to operative and invasive procedures.

- Authentication - All entries in the medical record must be signed, dated and timed.

- Legibility - All documentation in the medical record must be legible.

March 17, 2009

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