Prevail during your next Joint Commission visit

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Prevail during your next Joint Commission visit

Strategies to prep your nurses for surveyors

After reading this article, you will be able to:

  • Explain the four Rs for facing Joint Commission surveyors
  • List methods to prepare staff members for Joint Commission visits and relay necessary information throughout your facility

Priming staff members for inevitable Joint Commission visits is one of the most daunting tasks for ed-ucators, who continually look for effective training methods to convey the information your nurses will need when questioned by surveyors. With a proven, multifaceted training program under their belts, educators at a Rhode Island hospital share their secrets to survey prep success.

“With The Joint Commission now doing what they refer to as tracer methodology from point of entry to point of discharge, they would be speaking to everyone involved in care along that path,” says Raymond Thurber, MEd, RN, nurse educator at Kent Hospital, a 359-bed facility in Warwick, RI. “We said to ourselves, ‘How do we get the message to all 2,500 staff members?’ ”

Thurber and his colleague Linda Eklof Read, MEd, RN, decided to lead the organization’s Joint Commission (formerly JCAHO) education efforts in 2004. They developed a centralized program to ensure that all staff members received the necessary information and training.

Introduce staff members to the basics

The Joint Commission mandates that hospitals “ensure that staff understand how to comply with the standards” and instructs organizations to “develop programs to educate staff about new systems. The surveyors will interview staff members to see how well they understand your processes.”

First, make sure to educate staff members on The Joint Commission and its expectations, standards, and focus on tracer methodology. This education should take place several months before any planned visits but should also be a continual aspect of education, as many surveyor visits are unplanned, Thurber says.

The next step is to outline a list of various training activities so you are able to reach as many staff members as possible, Thurber says. At Kent, this involved introducing the following steps (the four Rs) for facing surveyors:

1. Relax. Take a deep breath, don’t get nervous, and take a few seconds to organize your thoughts.

2. Rephrase. Ask the surveyor to repeat his or her question if you don’t understand it.

3. Resources. If you are unsure of an answer, know where you can find it.

4. Respond. Answer the question as best you can; be brief and to the point.

Take a multifaceted approach

Once the staff members have a basic knowledge of The Joint Commission’s goals and how they should react to surveyor questions, it’s time to begin a multifaceted approach to relaying necessary information throughout the organization. To do this, Thurber and Read used:

  • Mock tracer surveys. Managers and staff members picked a patient diagnosis and followed the steps from admittance to discharge. “Administrators interacted with staff as if they were Joint Commission representatives, asking questions about a patient and following them through a continuum of care,” Read says.
  • Patient safety posters. National Patient Safety Goals were splashed on posters hung on the quality improvement hallways to inform staff members.
  • Newsletters. Thurber and Read used two internal marketing mechanisms—a weekly newsletter and a daily publication—to include pertinent Joint Commission information.
  • An education fair. Thurber and Read decided to devote the entire 2004 fair to Joint Commission training, as Kent Hospital was already conducting an annual mandatory education fair. The fair included functional work groups that focused on specific aspects of Joint Commission education (e.g., infection control).
  • Games. In further attempts to engage staff members, Thurber and Read instituted game-based learning, such as Joint Commission Jeopardy. (See “Kent Hospital: Joint Commission Jeopardy sample game” on p. 3 for a sample game.) The Jeopardy sheet includes questions that a surveyor might ask about ethics, medication management, and patient rights.

These efforts were far-reaching, but Thurber and Read didn’t stop there. They decided to develop a small educational booklet that was given to all hospital employees. Dubbed the “Survival Guide for Joint Commission,” this portable resource contained information on important regulatory topics, such as provision of care. Written in a question-and-answer format, the book was an immediate hit with staff members, Read says.


The Joint Commission (2008). “Preparing for a hospital survey.” Retrieved from


Adapted from The Staff Educator, October 2008, HCPro, Inc.