Essential Workflow and Documents for a Hospital Joint Commission Audit

When The Joint Commission comes knocking, hospitals must be prepared to present a wide range of documents that demonstrate compliance with standards in patient care, safety, and overall hospital operations to successfully complete their audit. Having a workflow to make the documents readily accessible is crucial for a smooth audit process and can greatly reduce stress on hospital staff.

Whether the visit is scheduled or a surprise, here’s a comprehensive list of the key documents hospitals need to provide during a Joint Commission audit as well as some tips and tricks for how process automation can make this experience a breeze for everyone involved.

Automating Compliance Documentation

One of the biggest challenges during an audit is pulling together all the necessary documentation, especially during an unannounced visit. Whether it’s organizational policies, employee certifications, safety protocols, or patient records, everything needs to be meticulously tracked and stored in a way that is easily accessible. This is where process management & optimization tools like Process Street can save the day.

With documented processes and automated workflows in place, hospitals can ensure that all compliance-related tasks are performed consistently and monitored in real-time. From credential tracking for nurses and doctors to fire safety drills, hand-washing audits, and equipment maintenance logs, process automation ensures that nothing falls through the cracks. When The Joint Commission walks in, everything you need is already organized and accessible with the click of a button.

1. Policies and Procedures

These are the foundation of any hospital's operations, outlining how the facility ensures patient safety, quality care, and compliance with regulations. The hospital must have comprehensive and up-to-date documentation for all its policies and procedures. Examples include:

• Infection Control Policy: Outlining protocols for preventing the spread of infections within the hospital.
• Medication Management Policy: Describing how medications are stored, administered, and monitored for safety.
• Patient Rights Policy: Ensuring that patient privacy and dignity are maintained, in accordance with HIPAA regulations.
• Emergency Preparedness Plan: Detailing the hospital’s procedures for handling natural disasters, mass casualty events, or other crises.

Process and documentation management tools can not only provide a readily accessible archive of Policy & Procedure information but also could be linked back to the key regulations   overseeing your organization to validate that your current processes are still best practice. One should also build a critical audit trail to demonstrate successful completion of any associated employee education, as that training or onboarding material can all be built, completed, and tracked directly within the system.

2. Employee Credentials and Certifications

One critical area of focus for The Joint Commission is whether all staff members are appropriately licensed and certified for their roles. Hospitals must provide:

• Licenses for Physicians, Nurses, and Technicians: Proof of current and valid medical licenses for all healthcare providers.
• Certifications for Specialties: Such as CPR, ACLS, or specialized training (e.g., in radiology or anesthesia).
• Training Records: Documentation that staff members have completed mandatory training, including safety drills, infection control, and patient privacy.

This is an area where an integration between your HCM or LMS system and process management tool can pay off dividends and save countless hours. Imagine having employees' important documents stored together in one location, monitored for currency, and accessible from all related process workflows.

Infection control is a major area of focus for The Joint Commission and healthcare organizations alike. Hospitals need to provide evidence of compliance with infection prevention standards, including:

• Infection Control Policies: Including hand hygiene, use of personal protective equipment (PPE), and isolation procedures.
• Surveillance Logs: Records tracking infection rates and any outbreaks.
• Sterilization Logs: Proof that medical equipment is sterilized according to protocol.

4. Patient Care Records

Patient safety and care quality are at the heart of The Joint Commission’s evaluations, and no doubt your own organization’s mission and values. The following documentation must be readily available:

• Patient Medical Records: These should demonstrate proper documentation of care plans, diagnoses, treatments, and patient outcomes.
• Discharge Plans: Documentation that shows how the hospital coordinates care and plans for patient discharge to ensure continuity of care.
• Informed Consent Forms: Records confirming that patients have consented to treatments and procedures after being informed of the risks, benefits, and alternatives.

5. Environment of Care Documentation

This category focuses on the safety and cleanliness of the hospital environment, ensuring that facilities are well-maintained and free of hazards. Documents include:

• Fire Safety Inspection Reports: Evidence that fire alarms, extinguishers, and emergency exits are regularly inspected and in working order.
• Hazardous Materials Handling Logs: Documentation proving that hazardous materials are stored and disposed of according to safety protocols.
• Maintenance Records: For hospital equipment, air filtration systems, and sanitation efforts, including HVAC maintenance and cleaning schedules.

As you’re collecting your EOC documents, have you considered the potential time saved via an automated reminder to review/record/inspect these areas of your organization? All organizations should have a review cycle that can be created to ensure there is never a lapse in recording this critical information or an unintended safety miss.

6. Quality Improvement Plans and Outcomes

Hospitals must show ongoing efforts to improve patient care and operational efficiency. Documents required include:

• Performance Improvement Reports: Evidence of quality improvement initiatives, such as reducing readmission rates or improving patient satisfaction scores.
• Outcome Data: Tracking key performance metrics like infection rates, mortality rates, and patient satisfaction surveys.
• Root Cause Analyses: Documentation showing that the hospital investigates adverse events and takes corrective actions to prevent recurrence.

If your Quality metrics aren’t being easily tracked and reported today, imagine the time back in everyone’s day to have an automated system that can provide regularly scheduled updates of the latest and greatest data. This is an incredible way to continuously highlight the incredible work your teams are doing on PI projects or RCA’s.

7. Medication Management Records

Proper medication handling is critical for both patient safety and regulatory compliance. Hospitals must provide:

• Pharmacy Inspection Reports: Evidence that medications are stored securely and according to temperature requirements.
• Medication Administration Records (MARs): Showing that medications were administered as prescribed, with proper documentation of dosages and times.
• Controlled Substance Logs: Detailed records tracking the dispensing and usage of controlled substances, including who accessed the medication and for what purpose.

8. Emergency Management Plans

Hospitals are expected to be ready for any type of emergency, whether it's a natural disaster, active shooter situation, or a public health crisis. The necessary documents include:

• Emergency Operations Plan (EOP): A comprehensive document outlining the hospital’s preparedness and response protocols for emergencies.
• Staff Training Logs: Proving that employees are regularly trained in emergency procedures.
• Evacuation Plans: Clearly defined plans for safely evacuating patients and staff in an emergency.

9. Equipment and Facility Management Records

Joint Commission auditors will want to ensure that the hospital’s facilities and medical equipment are safe and functioning properly. Required documents include:

• Medical Equipment Maintenance Logs: Proof that medical devices, such as defibrillators and imaging machines, are inspected and maintained regularly.
• Life Safety Code Compliance Records: Documentation showing that the facility complies with fire safety standards, electrical safety, and other life safety codes.

10. Safety Drills and Compliance Audits

Hospitals must be able to show that they conduct regular safety drills and compliance audits to identify and address any potential risks. This includes:

• Fire Drills and Evacuation Drills Logs: Evidence that the hospital regularly conducts these drills and records outcomes.
• Internal Audit Reports: Documentation of internal reviews of safety and compliance practices to ensure that the hospital is meeting Joint Commission standards.

11. Patient and Staff Safety Reports

Finally, documentation related to maintaining a safe environment for both patients and staff is essential. Examples include:

• Incident Reports: Records of any incidents involving patient safety, such as falls or medication errors, and the hospital’s response to those incidents.
• Workplace Safety Audits: Documentation showing that the hospital regularly audits workplace safety, including hazard assessments and corrective actions.

Does your organization have a mechanism today to help report on the outcomes of these critical audits, so your workforce has visibility into opportunities for improvement or areas to celebrate? The right tool with a comprehensive process catalog can bring this data to the front of everyone’s minds, which can aid in adherence to these critical processes.

Be Audit-Ready with Process Automation

A visit from The Joint Commission (or any regulatory body!) can be stressful, but process automation can ensure that hospitals are always audit-ready. By using tools like Process Street, hospitals can automate many of these compliance and documentation tasks, allowing staff to focus more on patient care and less on paperwork. Automated workflows ensure that key documents are consistently updated, policies are followed, and audit trails are maintained.

From infection control logs to employee certifications, process optimization keeps everything organized and easily accessible. So, when The Joint Commission walks through the door, you’re ready with every document they need, without scrambling.

What’s Next for your Organization?

Dr. Sarah Inman and Kai deSilva specialize in healthcare workforce management  and process optimization. Contact Improv today for a complimentary consultation on how to streamline your hospital’s compliance efforts and achieve maximum readiness for any regulatory visit.