The Joint Commission (TJC) accreditation occurs every three years to ensure White Plains Hospital is providing safe, effective, high-quality care to our patients.
The below Q&A aims to provide you with helpful information as to what to expect and how to best prepare for the upcoming Joint Commission Survey.
The Joint Commission (TJC) is a nonprofit organization dedicated to improving the quality of care in healthcare settings.
The TJC survey team will arrive unannounced any time from April 2025 and October 2025. The survey team is comprised of five surveyors who will arrive between 7:30 am and 8:00 am for a four-day survey.
The TJC survey team will conduct an unannounced survey at White Plains Hospital and all Outpatient Article 28 locations.
You should be prepared to communicate with Joint Commission surveyors during our accreditation survey and answer questions related to your practices and patient care.
- Wear your ID badge high and proud — ensure your name is visible, and it sits above your waist.
- Medications, needles/syringes must be locked and always secured — this includes locked carts, such as anesthesia carts.
- Review and ensure all documentation is complete and concise:
- Use of interpreter and documentation of ID number for patients whose preferred language is not English or refusal to use interpreter is documented.
- Consents must be dated and timed.
- Medication reconciliation is completed upon admission, transfer and discharge.
- All medication orders are complete and concise, including pain management.
- Preoperative, intraoperative and postoperative assessments are completed in a timely manner and documented appropriately.
- Are operative notes completed? If brief op note was written, ensure all required elements included.
- H&Ps and assessments contain appropriate evaluations prior to administering moderate sedation and pre-anesthesia assessment (with airway and ASA score for non-Anesthesia providers).
- H&P interval updates — were these dated and timed by a provider before the procedure?
- Discharge criteria from every procedural area — Aldrete scores and documentation before d/c.
- Post-discharge instructions from ambulatory areas include safety instructions for driving, mobility, etc.
- Blood transfusion orders to include time frame of administration.
- Use of oxygen requires an order.
- Time Out may be observed in the following areas: procedural areas, OR, L&D, ED, bedside procedures.
- Closed Medical record review — does the White Plains Hospital practice match the White Plains Hospital policy?:
- Restraints — all elements (order, alternatives, start/stop time and monitoring, plan of care present).
- Observation — orders for observation align with WPH policy.
- Discharge plan — instructions are clear, appropriate and specific, includes choices.
- H&P — all components required were included.
- Advanced directives — HCP, DNR, and goals of care discussion.
- Death — declaration of death, and documentation of autopsy when/if needed.
- Organizational quality performance improvement session discussion will include:
- Improvement efforts and quality initiatives related to IC, CLAB, CDiff, CAUTI, Falls, SSI, FMEA.
- Data review regarding antibiotic usage and communication of analysis.
- Contracts and PI associated w/contract services and contract including listing of quality metrics.
- Medical Staff Credentialing — FPPE/OPPE
- Review provider files to ensure clinical specific metrics regarding OPPE for every single specialty.
- Code of conduct: discussion regarding White Plains Hospital culture — how unacceptable behavior is addressed.