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Joint Commission Focuses on Culture, Improvements

Matt Phillion, for HealthLeaders Media, September 22, 2009

The Joint Commission has made significant strides to improve its performance and culture in 2009, the organization announced during its recent Executive Briefings in New York.

Ann Scott Blouin, PhD, RN, executive vice president of accreditation and certification operations, discussed at length major changes the healthcare accrediting body has taken in recent months to improve the way it works with hospitals, as well as its own internal processes. Among those improvements:

  • Refocusing surveyors. Blouin told the audience that The Joint Commission has refocused its 500 hospital surveyors to balance their roles as both evaluators and educators/coaches/mentors. According to Blouin, this was received as an invigorating change by "95%" of the surveyors.
  • Adaptation. The Joint Commission is using Lean, Six Sigma, and "change acceleration" to change its own culture. According to Blouin, there is a new focus on customer service and simplification of processes. The Joint Commission has also changed its tactics on criticality—now only direct impact Requirements for Improvement affect accreditation decisions.
  • Post-survey reports. The Joint Commission has promised to improve the time frame in which hospitals receive their post-survey reports. A recent study within the organization found that hospitals were on average receiving their reports 16.4 days after survey, with massive fluctuations in those timeframes—despite a requirement that hospitals receive this report within 10 days of their survey (not a 10-day average). A new process has been developed reducing the time to develop the report from 38 hours to 4.4 hours and the average timeframe to receive the report down to 5.4 days.
  • Periodic Performance Review. The Joint Commission is examining changes and enhancements to the PPR based on feedback from the field that the dates of submission are not working.

And, as was discussed earlier this year, there are no more automatic thresholds—there is "no magic tipping point," said Blouin. They have also made a concerted effort to reduce costs.

Looking ahead to 2010, The Joint Commission is taking a hard look at its National Patient Safety Goals to make sure accredited organizations are getting the most from their efforts to comply with these key requirements. Additional announcements on the NPSGs are expected in early October.


Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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