Preparing Nurses for a Joint Commission Survey

Anticipating the triannual Joint Commission accreditation survey can be stressful for caregivers. A team of nursing leaders at Cleveland Clinic Akron General revamped the preparation process to engage nurses and help alleviate their apprehension.

Previously, the nursing quality program manager and other staff from the Quality Department would occasionally round on nursing units prior to the survey and provide handouts to nurse managers to share with staff. Rounding focused mostly on the environment, such as making sure hallways were cleared and checking if any building repairs were required.

“What we needed to focus on for our Joint Commission rounds is what we impact the most – our practice and our documentation,” says Stephenie Kline, BSN, RN, nurse manager on general surgery, trauma, bariatric and orthopedic units at Akron General.

Hitting hot topics

The development of a collaborative, structured Joint Commission preparation process began in 2022, led by Chief Nursing Officer Sheila Miller, DNP, MSN, MBA, RN, who has since joined Cleveland Clinic London in the same role, and Kline, then nursing quality program manager.

With a focus on nursing-specific topics, Miller and Kline reviewed findings from a mock Joint Commission survey conducted by a consulting firm and identified 21 areas with gaps in practice. Based on those areas, they created content for nursing leadership rounds.

Leaders, including nurse directors, nurse managers, a clinical nurse specialist and members of the Quality Department, rounded on all units multiple times, during day and night shifts, between November 2022 and April 2023. Leaders would meet for 15 minutes prior to rounding to review the agenda, round on the units for one hour, then gather for 15 minutes afterward to evaluate how the process had gone.

Each round focused on several topics like glucometer cleaning, plan-of-care documentation, patient rights, suicide risk and pain assessments. Prior to rounding, nurses completed an assessment indicating how comfortable they were with each of the topics – not aware, aware but need a refresher or fully aware. The results helped the team prioritize topics and tailor rounding content to each nursing unit. 

“We created sample questions and answers related to each topic that would enable leaders to guide the discussion during rounds,” says Kline. “We assured the nurses that although they might not know all the answers, that’s why we were there – to educate them.”

Increasing knowledge and confidence

Kline says that clinical nurses were engaged and receptive to the new Joint Commission preparation approach.

“The goal of the rounds was to make caregivers feel comfortable and prepared for the Joint Commission survey,” she says. “We succeeded!”

Akron General’s Joint Commission survey occurred in May 2023, and the hospital earned its accreditation. Nursing leaders also used the rounding process to prepare for the hospital’s Magnet® redesignation visit last year.

“Nursing leader rounding created a friendly, positive environment and fostered an increase in knowledge and confidence among our clinical nurses,” says Kline.