If you’ve ever lived through a Joint Commission audit, you know the drill: a chime sounds overhead, and calm turns to chaos. Staff scatter. Documentation disappears. Anxiety spikes. But it doesn’t have to be that way.
Audit prep doesn't have to be frantic. You don't have to stay up all night with three different binders (wow, it’s like we’ve done this before) or rifling through file folders while a survey watches sternly over your shoulder as you try to find a document that you THINK (hope?!) actually exists. Yeah, that one has definitely happened to me. Getting there involves automating the right workflows so you can stop chasing paper and start showing up confidently.
Let’s break down what surveyors are really looking for, and how you can build a bulletproof compliance system without the binders and burnout.
Policies & Procedures - the “show me you’re not winging it” folder:
Surveyors want to see current, clearly written, consistently applied policies. That includes:
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Infection control (hellooooo, hand hygiene!!)
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Medication management
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Patient rights (HIPAA, privacy, etc.)
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Emergency operations (disasters, cyber threats, Alexa devices achieving sentience, etc.)
How Process Street helps:
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Build a digital SOP library that’s always up-to-date
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Assign policies to staff for sign-off (track who’s read what)
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Connect policies to onboarding or annual training workflows so they’re automated, tracked, and done
Staff Credentials & Licensure - because “I swear their CPR card is here somewhere” simply will not work.
You’ll need clean, current records showing:
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Licensure for all clinical staff
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Certifications (CPR, ACLS, PALS, etc.)
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Mandatory training completion (infection control, privacy, safety drills)
Your team can set up recurring workflows that will track expiration dates, alert managers before renewals are due, AND keep a digital paper trail ready for surveyor eyes (and out of filing cabinets. Yes, it’s actually that easy. (Check out our Case Study with Process Street to find out how automating clinical competencies can save WEEKS of time annually using a similar method.)
Infection Control Documentation – AKA “keep the germs out and your data clean!”
You’ll need:
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Infection surveillance logs
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PPE compliance audits
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Sterilization logs
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Isolation protocol documentation
We can build workflows that prompt your infection control leaders or department managers to input weekly logs, document compliance, and escalate anomalies. Once you add approvals for leadership review (yes, we can automate that!) then boom, the audit trail is complete.
Patient Care Records – because every clinician knows if it’s not documented, it wasn’t done.
Auditors want to see that your team are doing all the right things, but that’s not enough. You have to ensure you’re documenting them (accurately), too:
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Medical records
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Treatment plans
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Discharge instructions for continuity of care
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Informed consent forms
Pro tip: Use Process Street to audit EMR documentation practices monthly, fully automated with no need for sticky notes on the monitor for reminders!
Environment of Care (EOC) – because once you’ve ridden out a hurricane in hospital lockdown, you REALLY appreciate knowing someone has a plan!
You’ll need:
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Fire drill logs
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Hazardous waste tracking
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Equipment maintenance records
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Generator tests
Let automation do the heavy lifting:
We can use the awesome power of automation via Process Street to schedule and document inspections based on your specific timetable. You can attach photos, upload reports, and tag responsible departments for follow up.
Emergency Preparedness – because who calls 911 for 911??
You need documentation for:
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Emergency Operations Plans (EOPs)
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Training and drill participation
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Evaluation and improvement plans
Create repeatable workflows in Process Street that can guide you through those unspeakable (but sadly necessary) events, such as mass casualty drills.
Incident Reports & Safety Events – because what we measure, we manage.
Surveyors want (need) to see:
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Incident tracking (falls, near misses, med errors, etc.)
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Workplace safety trends
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Corrective actions and follow-up
This is REALLY cool – you can build a “Post-Incident Workflow” in Process Street to walk your team through:
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Reporting the event
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Root cause analysis
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Remediation steps
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Staff education follow-up
Quality Improvement & Performance Outcomes – show me the data!
If you’re making PI claims, you’ve got to be able to back it up with:
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Performance Improvement reports
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Outcome metrics
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Root Cause Analys (RCAs) from documented safety events
With Process Street, you can track your Process Improvement projects start to finish with corresponding dashboards so everyone can celebrate your awesome wins.
Medication Management – comes with everything but a built-in co-signer!
Required med management docs include:
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Medication storage and temperature logs
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MARs (Medication Administration Records)
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Controlled substance inventories (an area NO ONE wants to get wrong)
How closely are you managing your narcotics waste process? Set up a weekly or monthly controlled substance audit workflow in Process Street. Build checklists, require staff signoff, and tie it to shift reports or pharmacy logs.
Equipment & Facilities – because safety first, obviously.
You’ll need:
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Preventive maintenance logs
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Life Safety Code compliance docs
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Generator test results
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HVAC & ventilation inspections
With Process Street we can automate the scheduling of these checks, attach completed inspection sheets, and alert facility managers to overdue tasks. We love a little proactive compliance!
Safety Drills & Internal Audits – show your receipts, people.
Items you need to track:
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Fire, evacuation, and active shooter drills
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Internal safety and compliance audits (Code Pink, Code Black, etc.)
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Emergency call system testing
Need a cadence for the next bomb threat drill? You can build a master drill calendar in Process Street and assign owners, send automated reminders, collect documentation after each event, and store it all in one place.
Conclusions about Joint Commission Compliance
We’re all going to experience it over the course of our careers, but a Joint Commission audit shouldn’t feel like a fire drill. If it does, then I can point you to a workflow problem. And lucky for you (for all of us really), workflow problems are totally solvable. Process Street gives hospitals the tools to automate, assign, and track all the moving pieces of compliance with full transparency and accountability. No more file folders, no more missing signatures, and no more dread. Just a little automation between friends to help you and your staff zero in on what you need when it so every other moment can be spent where it matters most: at the bedside.
If you’re ready to stop dreading the survey cycle, we should talk. Dr. Sarah Inman and Kai deSilva are healthcare process geeks who actually like solving problems like these. At Improv, we help healthcare organizations modernize how they manage audits, compliance, and workforce operations via world class automation solutions like Process Street. Let us help you stop spiraling and start checking boxes the smart way.
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