Challenging Joint Commission

[Davey Do]

I had some fun in a recent thread with the results of a Joint Commission (JC) survey that allegedly showed the need for a staff member to act as a door so psych patients couldn't use community room chairs as ligature points. The situation is based in factual events and the response by allnurses' members was pretty much 100%: "That's dumb!"

Here's a link: https://allnurses.com/joint-commission-ligature-points-t699929/

Over 25 years ago, I was the nursing supervisor of a home health agency. We had been awarded JC's certification the year before and were up for a review. I don't recall the particulars, but when one surveyor proclaimed a need for a certain safety measure, I informed the surveyor that a P&P was already in place that covered that area of concern. The surveyor looked at me as if I had responded to her proclamation with a passing of odorous flatulence.

The administrator was present and basically assured the surveyor that a new P&P would be generated to cover that specific area of concern. The administrator then genuflected to the JC surveyor, kissed her ring, and the survey went on with good results. As I said, I don't recall the particulars, but it was inferred to me that JC is not to be challenged. When JC says, "Jump!", you do so.

I learned tonight from an administrator that the JC surveyors who proclaimed the need for staff acting as doors until locking doors on the community room can be installed were not prepared to survey a psych center. The administrator informed me that the surveyors were expecting to survey a 25 bed unit. Our medical center's psych division units total about 100 beds.

According to this administrator, "They went by the book", which meant the surveyors weren't prepared for, didn't know, or didn't have experience in dealing with such a large population, so they must have resorted to interpreting some documented guidelines.

If the surveyors were not prepared or experienced, why were they allowed to enforce seemingly ridiculous recommendations?

Has anyone ever challenged JC's recommendations, or are their decisions the be-all and end-all?

I did a little research, putting "Joint Commission challenged" in my search engine and generally came up with articles on some of the greatest challenges by JC. Except for one article by KevinMD, "Four Problems with the Joint Commission" which is a pretty good read, and this part stood out to me:

" When the Joint Commission reviews a hospital, the most critical component is an actual visit where members of the organization go to the hospital for around five days and observe the care provided firsthand. This sounds great— until you learn that their visit hours are about 8:30 a.m. – 5 p.m. Monday through Friday. Isn’t that odd? It’s hard for me to believe an organization truly cares about patient safety when none of their crucial observations are done during some of the most critical hours."

Here's a link: https://www.kevinmd.com/blog/2017/11/4-problems-joint-commission.html

So- do you know of any body or place that has challenged JC?

[klone, MSN, RN]

Yes, I have challenged a JC surveyor and won. In OB, we keep small quantities of sterile processed instruments on the unit (kits, individual peel packs of stuff, etc). The surveyor insisted that we needed to monitor temp and humidity in the room and keep a temp log. I insisted that we do not, because this clean utility is not "centralized sterile processing" but rather, an ancillary area to keep small quantities of instruments. I then showed her the document FROM HER AGENCY'S WEBSITE that states what I just told her, that ancillary areas (and the document even cited "OB department clean utility areas" as an example) did not have the same requirements to monitor temp and humidity. She then questioned the document's wording of "small quantities" and that is a subjective term and one could state that we had more than "small quantities" of sterile instruments in our clean utility area. I then stated that the document intentionally left it vague and up for interpretation of the individual facility as to how they want to define "small quantities" and our facility has determined that the amount we keep in our clean utility room meet's our definition of "small quantities" as evidenced by the policy we have on the topic (which I then produced for her to read).

It's been my experience that JC surveyors are human, and are subject to their own whims and biases when it comes to interpreting the agency's regulations.

[klone, MSN, RN]

Also, a lot of people don't realize that TJC isn't a governmental agency. It's a private, for-profit company that's contracted by CMS. There are other such agencies out there - a hospital doesn't HAVE to use TJC.

[klone, MSN, RN]

https://www.beckershospitalreview.com/quality/accreditation-options-selecting-an-accrediting-source.html

[Rose_Queen, BSN, MSN, RN]

My facility recently challenged a JC finding successfully regarding immediate use flash sterilization and how they calculated it vs. how it's supposed to be calculated.

JC surveyors definitely seem to each have their own focus- we had one about 6-7 years ago who focused almost exclusively on janitorial supplies and carts and didn't even look at some of the things we knew would be a problem/finding.

[LovingLife123]

I wish I understood TJC. I totally get in theory why they should be a good thing. They should, in theory, be making sure that facilities run properly. That they are clean, safe, and follow proper policy and procedure. They should be there to protect patients from facilities that can cause them harm.

But, that’s not what they are. They are a disillusioned entity that spends their time to simply find the most minuscule thing and make a huge ordeal of it. It’s gotten to the point where it’s absurdly ridiculous.

A facility using expired supplies? Yes, they should be cited. Making nurses write expiration dates on alcohol swabs? Absurd. I could go on and on on the petty, ridiculous things that they spend their time on. Like deciding that taping my strip of paper with my abg results in my room is an infection risk. Tape is an infection risk folks, even at the nurses station. Apparently though, that metal part on the pin, not an infection risk. Disposable tape equals infection.