How to Prepare for a JCAHO TJC compliance audit

Rather simply, .......  excel at everything that you do.

Compliance audits are required in many businesses and the best businesses simply do not worry about being audited. They are fundamentally prepared for any audit at any time since they have taken basic and fundamental steps that are necessary to run an effective operation that assures highest quality and best in class customer service.

The declared mission of JCAHO/TJC is "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value".

In comparison, ISO9000 standards were instituted in the late 80's with the intention of driving consistent practices and methods of execution throughout industrial companies. The goal was to improve quality and make national manufacturing more competitive.

But where did the ISO standards come from? .... From those practices used within successful companies. And how did those companies develop best in class practices.... they listened to their customers.

If one looks at the declared mission of ISO9000 it may read similarly to JCAHO "To continuously improve product quality, in collaboration with other stakeholders, by evaluating manufacturing organizations and inspiring them to consistently provide products and services of the highest quality and value, improve business efficiency, and increase customer satisfaction.

It isn't too far of a stretch to see that JCAHO will leverage much of the best lessons learned from ISO. One lesson learned was if an industrial firm spent more time preparing for an audit, than in running an effective operation, they failed to obtain a certification.

The most effective way for a hospital to prepare for an audit is to consistently outperform all other hospitals and thus become the standard for all others to follow. Rather than focus on what an audit might require, focus on quality, customers, error reduction, consistent outcomes, repeatable high performance execution, singular methodologies of work, removal of barriers, integrated teams, document and data management, systems thinking, structured methods, checklists, and more. 

Regardless of specific activities, assure that these focus points become basic and fundamental in the operation at your hospital, since they are what will form the basis for most all specific standards.

Worried that the standards are ill-defined and changing? Expect that to continue. Concerned that you will need to comply with a moving target? You need not worry if you focus on those basic principles upon which the specific standard will rely.

• Focus on excellence and don't worry about audits.

• In simple terms: if you are doing it right, showing it is easy.

• If you are running an inefficient practice, the audit will be onerous, difficult and costly.

• If you want a guide to implementing a compliance plan, benchmark ISO9000 and implement many of the basic elements contained therein.

• If you want a specific approach, create an "Evidence Book". An evidence book is the collection of all materials (documents, results, changes, etc.) that are relevant to a department, division, project or individual task. The evidence book can be structured as a systemic representation of the workflow and can, when required, be used to demonstrate the efforts made in response to a particular activity.

If you implement an effective evidence book methodology, you will be prepared for an audit at any time. 

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[freelance writer]

now i know how to prepare for a JCAHO TJC compliance audit