Healthcare Workers' Strategies for Navigating the Joint Commission's National Patient Safety Goals

In the ever-evolving landscape of healthcare, ensuring patient safety remains paramount. As a leading accrediting body, the Joint Commission (TJC) sets the standards that healthcare facilities must meet to provide high-quality care. To assist with this, TJC prepares yearly “National Patient Safety Goals” (NPSG), which can serve to assist healthcare facilities as they prepare for their audits. 1
At CIVCO, we understand that real-world insights and practical advice are invaluable when preparing for TJC audits. In our previous post, “Deciphering The Joint Commission National Patient Safety Goals for 2023,” we explored the "what" of TJC standards, breaking down several of the individual safety recommendations put forth by TJC in 2023. Now, in this companion piece, we’ll delve into the "how.” 
Below is a compilation of firsthand perspectives and actionable strategies from dedicated healthcare professionals, all of whom are on the frontline of patient care – and all of whom have insights that can help you prepare for your own audit. Join us as we delve into the strategies, tips, and experiences that will empower you to excel in meeting TJC's 2023 National Patient Safety Goals and safety standards. Whether you're a seasoned healthcare veteran or just starting your journey in this vital field, this article is your key to ensuring patient safety and achieving compliance with confidence. 

Infection Prevention Tips from the Front Lines 

For most healthcare facilities, infection prevention represents one – if not the – largestHand Washing 
area of focus regarding TJC audits. “Infection prevention is always a concern and
one of the most cited areas,” said Steve, Emergency Nurse.
For The Joint Commission, preventing infection can mean many different things across many different clinical focuses – both concerning individual and material standards. “Equipment being cleaned/sanitized per manufacturer guidelines [is one example],” said Steve. 2
This extends to ultrasound probes, as well – particularly with maintaining full compliance with their cleaning procedures, which can be challenging, especially when budgets don’t align. “The budget is not always available to have the “top of the line” equipment, such as automated systems and cabinets with HEPA filters,” said Heidi, who often helps healthcare professionals navigate the ultrasound probe infection prevention challenges. “I think what is challenging…[is] having to retrain on compliance and keep the policies and procedures buttoned up. Knowing what is compliant compared to what is not and where to find the information.” 3
Other aspects of infection prevention that continue to be relevant in TJC audits include personal cleanliness – “Hand hygiene also continues to be a point of emphasis,” said one SDMS member 4 – and how educated healthcare workers are with regards to their cleaning products – “Whenever we are due to be audited, we are quizzed on the “wet times” for all the different Sani Wipes. 2 minutes for purple top; 4 minutes for gold top,” said Kellie, Registered Nurse. 5

Mastering Documentation, Record Keeping, and Education 

Record KeepingWhen it comes to TJC audits, maintaining proper documentation and record keeping of educational requirements appear to be an oft-mentioned area of focus by many healthcare providers – a fact that lines up with the Joint Commission’s website and policy priorities. 6
Diane, ED Clinical Education Specialist, emphasized the significance of having detailed documentation of training prepared and ready, saying, “For the most part, what I see is an interest in documentation of staff training. TJC is focused on record keeping and on documentation of what was taught, i.e. the procedures need to be well delineated. They also look for what our decision processes were in determining who to train and how often to reinforce training.” 7
It’s a sentiment shared by other healthcare professionals, including one SDMS member who stated, “Having well-established pre-HLD cleaning steps, probe transport containers, proper PPE and compliance with annual training & individual competency check-offs are important components…Also, individual personnel files with documentation for age-specific population competencies [is] important.” 4
Leanne, Clinical Educator Specialist, further underscored the crucial role of education documentation in audit preparation. She advised, “The NPDS work with HR, leadership, and quality and risk management to determine the frequency of education, and then work with managers to ensure that participation is completed and marked on their records (via LMS or other methods) for staff.” 8

Real-World Strategies for Keeping Workspaces Clean

In the lead-up to a TJC audit, the clinical setting often transforms into a whirlwind of activity, with one common goal at the center: ensuring that everything is in impeccable order for the auditor. Leanne, Clinical Educator Specialist, provided a vivid picture of this, emphasizing the importance of maintaining a pristine environment. “The unit needs to be in top shape,” she said. “No cardboard boxes, nothing within 18 inches of the ceiling, temperature checks completed on all refrigerators… Clean, clean, and clean!” 8
Kellie, a Registered Nurse, echoed this sentiment, reinforcing the importance of maintaining cleanliness and organization within the clinical setting. “Environment of care and infection prevention always pop into my mind…no open containers at the nurses' station… how far off the ground and from the ceiling we can stock supplies, etc.….,” she explained. “I know we put in a lot of engineering tickets to have stained ceiling tiles changed out for clean ones. At one point, they wanted us to RLT (or "write up") whenever we saw dust bunnies in the hallways so we could get everything deep cleaned.” 5

Insights on Medication Management Compliance 

Medication ManagementMedication management within healthcare facilities is complex, requiring precision and unwavering attention to detail. Leanne, Clinical Educator Specialist, underscored the critical importance of medication storage and administration standards. "Medications [should be] stored correctly," she emphasized, "all dates checked for expirations, [and] anything that is multiple-dose [should be] dated and initialed." 8 The message is clear: medication compliance is not a part-time endeavor but a continuous commitment. Medications must always be appropriately marked and administered without exceptions.

Kellie, a Registered Nurse, added another layer of complexity to the issue by highlighting the particular scrutiny often paid towards pain medication administration. “I know that we are also audited on pain medication administration,” she explained. “For example, based on the patient’s pain level, did we give the appropriate medication, and did we reassess their pain level within an hour?” 5
Steve, an Emergency Nurse, further emphasized the comprehensive nature of medication management audits. “Is medication titration, vital sign documentation, [and] consents completed per policy?” he cited as some of the more common aspects of medication management during TJC audits. 2
Julie, Chief Nurse Officer, highlighted her facility’s proactive approach to remain ‘regulatory ready.’ “One way we accomplish this is through our daily “GEMBA rounds,”” Julie explained. “On Tuesdays, we do a “Joint Commission Tuesday” approach, [which sees] each week [have] a different focus, such as med management…” 9 This type of approach demonstrates a commitment to readiness, ensuring that compliance is not a last-minute effort but a consistent part of a facility’s healthcare culture.

Overlooked Aspects of TJC Compliance

When prepping for TJC audits, it’s easy to miss certain critical aspects – those items of attention that often get paid during audits but are all too often neglected during audit preparation.
For instance, one Clinical Educator highlighted the significance of vendor roster records. She noted, "The newest thing they [TJC auditors] are asking for is vendor roster records. I would encourage anyone going forward to make sure you have those records so when they ask, you can produce." 10 Such advice underlines the importance of having thorough and up-to-date records - even in areas that might not be immediately obvious.
Additionally, Stephanie, an Adult Health Clinical Nurse Specialist, underscored that auditors may zero in on specific standards, such as those related to cardiac patient care. “They focused on specific standards for cardiac patients, including following the latest guidelines, nurse and physician education, etc.,” she explained. 11
These “under-the-radar” insights from healthcare professionals highlight the importance of employing a holistic approach to TJC compliance – including the most well-known standards and the oft-overlooked aspects. 

Achieving Successful TJC Audit Doesn’t Just “Happen”: 

Achieving A Successful TJC Audit Doesn't Just HappenIn conclusion, navigating the multifaceted requirements set forth by The Joint Commission demands a comprehensive approach. As we've explored the key takeaways from healthcare professionals on infection prevention, documentation, workspace cleanliness, medication management, and often-overlooked aspects of TJC compliance, it becomes evident that success in meeting these standards requires diligence, precision, and an unwavering commitment to patient safety.
At CIVCO Medical Solutions, we recognize the challenges healthcare facilities face in preparing for TJC audits. Our expertise and solutions can assist you in achieving compliance with confidence, ensuring that you are well-prepared to meet TJC’s rigorous standards and provide the highest level of care while prioritizing patient safety.

TJC requirements are complicated, and there is a lot to consider. However, with the right strategies and partners like CIVCO, you can successfully navigate these challenges, providing high-quality care while meeting the rigorous standards The Joint Commission sets. Your commitment to patient safety is paramount, and we're here to help you achieve it.

#1: Joint Commission National Patient Safety Goals 2023
#2: TJC Audit Feedback – “Steve”
#3: TJC Audit Feedback – “Heidi”
#4: TJC Audit Feedback – “SDMS Member”
#5: TJC Audit Feedback – “Kellie”
#6: Competency Assessment vs. Orientation: The Human Resource (HR) chapter of the accreditation manuals include requirements for ‘orientation’ and ‘competency assessment.’ How do these activities really differ from each other?
#7: TJC Audit Feedback – “Diane”
#8: TJC Audit Feedback – “Leanne”
#9: TJC Audit Feedback – “Julie”
#10: TJC Audit Feedback – “Clinical Educator”
#11: TJC Audit Feedback – “Stephanie”