Performance Improvement wanted to share the Hospital and Behavioral Health’s progress related to compliance with Joint Commission required documents.

The first graph below shows that for the Hospital, 70% of the Joint Commission identified required documents have been reviewed, with 48% compliance and 22% non-compliant.  A “non-compliant” document is one in which the document:

1.      Doesn’t exist.

2.      Is not in the appropriate template format.

3.      Is out of date and needs to be updated (older than 2 years).

4.      Contains the incorrect approval path attached.

Almost 30% of the documents have not been reviewed by PI/department team.

The below graph shows the progress made for the Behavioral Health required documents.

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The below graph shows the progress made for the Behavioral Health required documents.

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How can you help with the progress, and ultimately with your departments readiness for an onsite Joint Commission Survey?

1.       Review your department’s required documents (policies, procedures, plans, logs, etc.).

2.       Decide what needs to be done with the document (Retire? Separate into templates? Revise? Apply correct approval path?).

3.      Fix the document in Policy Manager.

4.      Let your PI partner know.

A friendly clarification: 

During the Joint Commission survey prep (ICM – Intra-cycle Monitoring Process), PI is “acting” as a Joint Commission surveyor.  It is our responsibility to determine whether the areas affecting your department(s) meet TJC requirements.

You and Your department(s) are the onwer, not only of the documents, but also of the manuals under which your areas fall.

Please feel free to contact Jaye Marcus-Ledford, LMSW, PI Administrator, at 907-543-6131, if you have any questions.

PI appreciates all of your hard work, especially during this COVID pandemic, but we can’t forget that we still must meet Joint Commission/CMS requirements.