How to Prepare for the Joint Commission

The Joint Commission (TJC) is a non-profit agency responsible for the accreditation of more than 21,00 healthcare organizations. The agency’s accreditations are used as a condition to determine the receipt of CMS reimbursement, and therefore, greatly influence hospitals’ bottom lines and yearly revenue.

With three-year accreditation cycles and unannounced survey dates, preparing for the Joint Commission generally incites much anxiety among healthcare leaders. Organizations must be up-to-date with and in compliance of all standards, processes, policies, and procedures. This is no small task, and usually requires significant time and resources to ensure certification is met with little risk of standards being cited for improvement.

How are hospitals preparing for a Joint Commission Visit?


Depending on an organization’s current focus and internal initiatives, leaders may choose to implement technologies to help comply with specific standards, such as using care coordination software to receive the integrated care certification. While this type of program is helpful for the certification process, it is usually limited in scope and can leave organizations vulnerable to surprises and potential citations.

Joint Commission Readiness Rounds

One of the most effective ways to ensure consistent preparation for a Joint Commission visit is by performing Joint Commission Readiness Rounds or “tracer” rounds. These rounds “trace” what the Joint Commission would do to determine if hospitals are meeting the latest procedures and standards. This process, which is similar toEnvironment of Care (EoC) Rounding, allows organizations to adjust to new policies or procedures.

What makes Joint Commission Readiness Rounds different from other types of EoC rounds is that they are rather lengthy, incorporate several teams within the hospital, and rely on up-to-date information on TJC standards.

Addressing the Challenges of Preparing for the Joint Commission 

A prominent challenge that organization’s face is devoting the time and attention to address every standard or procedure that the Joint Commission reviews, without anything being overlooked or mistracked. To address this issue, Joint Commission Readiness Rounds have been divided into topics such as:

  • Environmental Rounds
  • Safety Rounds
  • Infection Prevention Rounds

These topics were then segmented to test employee knowledge and increase staff engagement. Additionally, the rounding scripts were divided amongst a range of managers, beyond just nursing or quality managers.

How to Enhance Joint Commission Readiness Rounds

In order to better track and trend data to ensure all units are prepared, hospitals are leveraging digital rounding software, similar to CipherRounds. One of the advantages of utilizing rounding software is the ability to easily gather information that can later be analyzed to determine the areas in need of improvement.

In addition to leveraging data in a more effective way, digital rounding technology can also streamline the issue resolution process, ensuring teams can quickly address and fix potential issues before they are flagged. With rounding software like CipherRounds, alerts can be configured to notify nurse managers and ancillary departments of issues, leading to timely resolution.

While preparing for the Joint Commission can be time-consuming and stress inducing, using evidence-based software and technology to streamline processes, analyze data, and drive improvements facilitates continual readiness. To see how our environment of care rounds can positively impact your organization’s processes, click here.

Ranked as the “Best Overall Patient Engagement Company” in MedTech's Breakthrough Awards for 2020, and the top-performing vendor for patient outreach and digital rounding by KLAS in 2019, CipherHealth is a proven technology partner committed to enhancing communication and coordination throughout the patient journey. CipherHealth’s suite of patient engagement software empowers healthcare organizations to foster meaningful connections to ensure the best possible outcomes for staff members, patients, and their loved ones.