It’s time once again for the annual (internal) Joint Commission Intra-cycle Monitoring (ICM) conducted by the PI team.  Although no longer mandated by TJC, the ICM is an excellent method of gauging YKHC’s readiness for an onsite survey by TJC.

Due to COVID 19, PI will not be holding the ICM Kick-off meeting.  

PI requests that the ICM be taken as seriously as if this were an actual TJC onsite triennial survey.  The results of the ICM will provide an idea of the strengths and opportunities for improvement in the area(s) you work, as well as providing SLT with a gauge of where we stand as an organization for an upcoming TJC survey.

Each Chapter of the Joint Commission Manual is assigned a Chapter Leader and a PI Team member.  The individuals meet and review the Elements of Performance (EP) and determine whether the policies, procedures, processes, logs, etc. are in place, up to date, and compliant or non-compliant with the EP.

The goal of our organization is to pass the Joint Commission onsite surveys with minimal findings in the Chapters that each department is responsible for covering.  

The best way to do this, is to “Make every day Joint Commission Day”

Thank you for all that you do to make YKHC a place where everyone receives quality and safe care!