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Stay Joint Commission ready! Steps we are taking

What’s next? Three major improvement areas

Thanks for participating in our recent Joint Commission survey. You may be wondering, what’s next? What were the results?

Surveyors found three conditional findings or areas where we need to demonstrate improvement in order to renew our accreditation. Those three areas are below, and you’ll notice we’ve begun addressing the first two (read the PRACTICAL MATTERS section in this Common Ground edition):

  • Ligature risk in the psychiatric unit
  • One-on-one suicide risk observation
  • Environmental conditions in the operating room

Two surveyors from the Joint Commission will return any time within 40 days to reassess these conditional findings. However, it is imperative that we maintain survey readiness across all areas. When the two surveyors return, they may make observations and note additional findings in other areas.

As a leader, the organization needs you to help your staff understand their continued role in being Joint Commission ready. Please communicate the work that needs to be done so that we can resolve the conditional findings.

You and your staff may be asked to participate in resolving the conditional findings and maintaining readiness. This work is important, and executive leadership supports staff in making it a priority. If you have concerns, please discuss them with your leadership.

Additional information is available on the RegReady intranet site, and we will provide further communications as the details of the Joint Commission report become available.

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