Joint Commission to carry out recertification review for comprehensive stroke care

June 4, 2018  //  FOUND IN: Updates & Resources

Please be advised that the organization has received notification that The Joint Commission On-Site Review for comprehensive stroke care will take place on June 12 and June 13.

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

On Day One, there will be 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.

On 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 the organization will hear TJC’s findings regarding 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.

Here are some things to keep in mind as you prepare for the visit:

  • If you are in a clinical area, please visit this updated website for area-specific review questions.
  • Please ensure that blue folders are assessed. The reviewer could narrow in on any of the criteria below; primarily standard documentation and policy for any staff within the institution, but please pay special attention to 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 (annual stroke education is required for all staff throughout the institution)
    • Annual performance evaluations are complete and current according to institutional guidelines

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