The Joint Commission Comprehensive Stroke Center Survey

June 5, 2016  //  FOUND IN: News

This is an alert that we have received notification that The Joint Commission On-Site Review will take place June 13th and 14th!

There will be two reviewers for two full days.  As stroke patients are cared for throughout our institution, patient tracer activities by the reviewers can occur anywhere within the University Hospital or Cardiovascular Center.

Day one, we will have an opening session followed by individual patient tracer activities. During the tracer activities, TJC reviewer teams will visit various patient care units and procedure/support areas following the path of the patient. The reviewer teams will be interviewing patients and staff with regards to caring for the stroke/cerebrovascular patient population.

Day two, the individual patient tracer activity will be continued. Additionally, there will be a competency/credentialing session and a data metric presentation, followed by a closing presentation during which we will hear TJC’s findings regarding our certification status.

The Joint Commission is an independent, objective evaluator of quality.  Their mission is to improve the safety and quality of care provided to the public.  The Joint Commission certification program is an evaluation based both on demonstrated compliance with the standards, and on evidence that the program effectively uses clinical practice guidelines and outcomes measurement to improve care on a continual basis.

  • If you are in a clinical area, please see our updated website for area-specific review questions
  • Please ensure that the blue folders are assessed.  The reviewer could narrow in on any of the criteria below; the bulk of this is standard documentation and policy for any staff within the institution, but please pay special attentio the underlined areas below to ensure that staff have had the required training.  
  • Practitioners have educational backgrounds, experience, training and/or certification consistent with the program’s mission, goals, and/or objectives
  • All practitioners hired have a current license and competency is established.
  • All practitioners have current licenses
  • Current licensure is verified from primary sources
  •  Orientation was conducted/relevant and documentation is available  if requested
  • Participation in required continuing education was conducted/relevant and documentation is available if requested

If you have any further questions or concerns, please contact the Operations Director for the CSC, Jenevra Foley at