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Current Focus Areas for Joint Commission Accreditation Surveys

by Mary Lou Weden on Jan 19, 2016 4:44:00 PM


The Joint Commission (TJC) provides focused insights and educational resources on the emergency management standards for health care organizations. Each year TJC concentrates on providing an overview of accreditation focus areas for emergency management. The following information highlights the current TJC focus areas.

Emergency Management Oversight

Leadership accountability for the emergency management program can be found in both the emergency management and the leadership chapters of TJC accreditation standards. Those standards require the following:

  • The organization must identify a leader to oversee emergency management
  • The organization must consider input from various staff levels when evaluating responses to exercises and events
  • The organization’s senior leadership must review the emergency management program and its associated activities

Please note that these areas of leadership fall outside the scope of the incident commander role and responsibility. 

Evaluation of the Effectiveness of the Emergency Management Program

The organization must evaluate the effectiveness of the emergency operations plan (EOP) by involving a multidisciplinary process with relevant input from all levels of staff affected. Any deficiencies and opportunities for improvement need to be communicated and shared with the members of the Environment of Care team and hospital leadership. 

Inclusion of Hospitals in Coalitions Building

In an effort to mirror grant focus on coalition building, TJC is also focusing on the hospital including coalition building and/or participation as part of its EOP. During large events that impact a community, individual facilities have limited stores of supplies and equipment. Vendors that would normally be utilized to supply additional supplies and equipment to manage surge are often the suppliers for multiple facilities in a region. This results in an inaccurate scope of available resources, thus diminishing any single facility’s ability to manage needs during surge. Participating in coalitions within a geographical location helps ensure that facilities work together to maximize the available resources instead of creating competition for those resources during a time of need.

Fullfilment of All Hazards Approach Requirements

Disasters are unpredictable. When hospitals focus their planning efforts to address the identified critical areas for all possible vulnerabilities identified in their Hazard Vulnerability Analysis, they have taken an 'all hazards' approach. In doing so, they will have a comprehensive EOP that is also scalable to disasters of any size and duration. TJC surveyors will focus particular attention to how organizations address these areas throughout their EOP. The six critical areas include:

  • Communication
  • Resources and assets
  • Safety and security
  • Staff responsibilities
  • Utilities management
  • Patient clinical and support activities


Standard Inventory Requirements

Standard 03.01.01 EP A3 requires that the hospital conducts an annual review of its inventory. Although this is not a new standard, there will be increased scrutiny on it during reviews. Not only do organizations need to show that they have adequate quantities of supplies available, but also need to show that they have a plan for obtaining additional needed supplies and equipment during disasters. Plans need to address scenarios where the normal channels of obtaining supplies are not available. Planning in this manner helps ensure that supplies are available to adequately care for patients.

For more information about current focus areas for THC accreditation surveys, please contact your Intermedix client services representative.


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This post was written by Mary Lou Weden

Mary Lou Weden is a product manager, business solution - Systems at Intermedix.

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