What I Wish I Knew - How to prepare for accreditation visits from the Joint Commission (TJC)

Robin Hieber, PharmD, BCPP
Clinical Pharmacy Specialist – Inpatient Mental Health
Residency Program Director – PGY2 Psychiatric Pharmacy
Captain James A. Lovell Federal Health Care Center (FHCC)
North Chicago, Illinois

Dr. Hieber has been practicing in mental health pharmacy for over 13 years, surviving numerous accreditation processes over that time. She has experienced accreditation visits from The Joint Commission (hospital accreditation), the Office of the Inspector General (clinical pharmacy review), American Society for Health System Pharmacists (pharmacy residency programs), and the Accreditation Council for Pharmacy Education (pharmacy school). Her practice sites have always been inpatient psychiatric units, though she also spent three years as clinical faculty for a college of pharmacy.

What TJC is and what you can do to be prepared for it?

The Joint Commission (TJC) is an independent accrediting organization that has been around for nearly 70 years. Their role is to visit health care organizations (HCO) across the nation to ensure that we continue to practice safe and effective care at the highest quality. Accreditation by TJC is a distinction held by 21,000 HCOs and demonstrates that the facility is dedicated to the delivery of quality care; the HCO is then re-accredited every three years. The TJC reviews hospital, ambulatory, behavioral health, home-health care, and laboratory services and appear to be expanding services further.

My experience has been primarily with behavioral health accreditation visits though perhaps these tips can be translated across services. Most of the time, the facility should have an awareness of when TJC will be coming for a site visit; however, you are given a more general timeframe such as which month(s) and then usually a 7-day notice for their arrival. Most facilities have a plan in place to alert all staff upon arrival of TJC so that everyone can be on his/her best behavior. I personally think it’s most helpful to remind us to be doing those things we generally do but on occasion forget, such as wearing your badge on the unit, and to able to quickly review any relevant standards that are likely to arise when they visit.

BEFORE TJC arrives, it’s best to have awareness about what standards/National Patient Safety Goals (NPSGs) are relevant to you and how you/your department can assist in ensuring the facility meets or exceeds those standards; this will be discussed in more detail in the next section. Every facility, big or small, should have at least one employee, or entire department, whose job it is to make sure the organization is continually focused on performance improvement. Generally speaking, your facility should address each standard within a policy/group of policies by which the employees should operate. Expect that TJC visitors will ask anyone and everyone questions, so make sure if you have students or residents that they know pertinent standards. Please make sure EVERYONE knows NOT to make up an answer. You, or the performance improvement people, will possibly be asked to produce the policy to verify the answer you’ve given. You are always allowed to respond that you are unsure, believe there is a policy relating to the question, and offer to return with the answer later in the day. They are only around a few days though, so the turnaround time will need to be speedy for you and the facility to be compliant on the measure.

AFTER TJC has been to your facility, you will have 60 days to correct any areas of non-compliance.

What TJC measures/standards may apply to you and your practice site?*

• Hospital-Based Inpatient Psychiatric Services (HBIPS)
  • HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification
    • For patients leaving an acute unit on more than one antipsychotic, only THREE reasons are considered acceptable: 3+ failed monotherapy trials, plan to taper to monotherapy in outpatient setting, augmentation of clozapine – key here is documentation at discharge and education.
• Medication Management (MM)
  • MM.01.02.01, MM.01.01.03: High alert/hazardous and sound-alike/look-alike drugs (SALAD)
    • You should have a list of high alert/hazardous/SALAD medications and a policy for how they should be handled (this is actually two separate policies at my facility, for example)
    • The Institute for Safe Medication Practices (ISMP) and the National Institute for Occupational Safety and Health (NIOSH) are excellent resources for aiding in development of such policies
  • MM.03.01.01, MM.03.01.01, MM.05.01.09.: Storage, labeling and dating of medications, particularly vials
    • Make sure pharmacy and nursing are appropriately labeling/storing vials (trust me, if ONE vial isn’t labelled properly, they WILL find it)
  • MM.02.01.01: Managing medication shortages
    • Communication practices AND development of strategies on how to handle shortages to mitigate risk (anyone having flashbacks to the benzodiazepine shortage?!)
  • MM.02.01.01: Formulary management
    • Have a formulary available/searchable for all providers and ensure appropriate monitoring for measurement of response & safety of medications BEFORE adding to formulary (and of course actually DOING the monitoring). Education/training should be available to staff on an ongoing basis.
  • MM.03.01.03: Management of emergency medication
    • Which medications do you allow immediate access to nurses and have you justified how this will be done safely?
  • MM.03.01.05: Patient’s own medications
    • Develop a policy on management of medications that patients bring to the facility. This will often state that patients are not allowed to take their home medications while hospitalized. In addition, the policy may include how long the home medication will be stored before being destroyed.
    • This can be a storage or wastage nightmare depending on how you handle it but every facility needs a plan in place.
  • MM.04.01.01: Medication orders
    • Have a policy identifying allowable types of orders (i.e. we don’t allow PRN orders without an indication, and some also need specific parameters…)
  • MM.05.01.01: Review of orders
    • Have a system in place for processing of orders to check for allergies, interactions, necessary labs, etc.
  • MM.7.01.03: Adverse drug events and medication errors
    • Is there a process to respond to events to improve future outcomes and that ensures appropriate reporting when necessary?
• Information Management (IM)
  • IM.02.02.01, IM.02.02.01 EP 2: Abbreviations
    • This is making sure the facility utilizes ONLY accepted abbreviations (perhaps you have a list of unapproved abbreviations like we do)
    • The ISMP is also helpful with providing further details
• National Patient Safety Goals (NPSG)
  • NPSG.01.01.01: Use 2 identifiers when providing care, treatment or services
    • If you/trainees speak to patients, this is a MUST!
  • NPSG 3: Improve the safety of using medications
    • Medication reconciliation falls under this – how good does your facility accomplish this at all treatment points (i.e. inpatient, outpatient, discharge, transfer)?
    • Educating patients on their medications and having patient provide informed consent also falls under this goal

*This is definitely NOT all-inclusive but hopefully a decent start

General do’s and don'ts

• Do know your organization’s performance improvement personnel
• Do understand the relevant standards at your facility/area of practice and what you can do to help improve/develop policies
• Do develop a workgroup/ad hoc committee for standards your facility struggles with
• Do bring in residents/students into the fold so they can learn (residents are also great for providing inservices to staff on new/revised policies etc.)
• Do develop brief tutorials on particular standards needing improvement in your facility, be it via email or inservices (and READ the emails that are sent to you on this topic)
• Don’t procrastinate
• Don’t be afraid to ask for help
• Don’t make excuses unless you really are CURRENTLY working on a policy/protocol change

Conclusion

Try not to fret about accreditation visits, but the more prepared you are the better you will feel! Remember the employees of TJC are human beings and they generally take their jobs very seriously. It is fine to exchange pleasantries/suggest restaurants but try not to veer them off task. Good luck and keep in mind this is meant to IMPROVE patient care first and foremost, not just make your job more difficult no matter how it feels!

Reviewed and updated by Michele Thomas, PharmD, BCPP, June 2023