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Preparing for a Joint Commission Survey: An Innovative Approach to Learning

Campbell, Rebeka Watson; Leger, J. Michael

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Nursing Education Perspectives: 9/10 2020 - Volume 41 - Issue 5 - p 315-316
doi: 10.1097/01.NEP.0000000000000708
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Understanding the role of accreditation standards in the provision of care in a hospital environment is a daunting task for a graduate nurse (Manzo et al., 2012). Two areas of an accreditation survey that are most likely to impact staff nurses are a survey of the Environment of Care (EOC) and an audit of the patient care record (Provision of Care [POC]). In addition to demonstrating an understanding of the nurse’s role in minimizing patient safety risks in the health care environment, learning to document appropriately is arguably one of the most challenging skills for the novice nurse (Hofler & Thomas, 2016). Experience in applying the principles of the nursing care process, or POC, as demonstrated through nursing documentation to reflect assessment of patients’ needs, planning/providing/coordinating care, treatment, and services, is often lacking. Reasons for this gap in knowledge include lack of exposure and guidance, limited practical experience, and lack of familiarity with the electronic health record (EHR).


In an effort to facilitate nursing students’ transition to practice as graduate nurses who are prepared for expectations of a site visit from an accrediting body, the University of Texas Medical Branch at Galveston (UTMB) Health System and UTMB School of Nursing (SON) piloted an educational initiative as a collaboration between the health system’s Department of Quality and the SON’s BSN clinical capstone course. The goal was twofold: 1) to provide nursing students with opportunities to apply accreditation standards in real-time clinical settings and situations while integrating this applicable knowledge into their future professional nursing role, and 2) to utilize the nursing student as a quality auditor extender in an effort to build a culture of continuous compliance and readiness for accreditation site visits through focused data collection efforts (Joint Commission, 2019).

The capstone course serves as the final practicum in an entry-to-practice BSN program. The course has limited didactic hours (7.5), moderate lab hours (22.5), and a robust amount of precepted clinical hours (135), all subject to completion in a seven-week period. This educational activity specifically aligns with several of the capstone course objectives: 1) provide safe, competent, compassionate, and holistic care to individuals and families based on theory and evidence; 2) use effective oral, written, and technology-based communication strategies to facilitate professional relationships and collaboration with interprofessional teams, patients, and families; 3) use standards of practice to manage and coordinate nursing care in collaboration with an interprofessional team; and 4) apply the principles of leadership and management in collaboration with an interprofessional team. The overarching objective for the course is preparing students for entry into practice and enabling a seamless transition to professional nursing.

Each quarter, Quality Department staff perform approximately 50 EOC and 200 POC reviews as random, unannounced audits; these translate to 300 person-hours for data collection. In today’s cost-conscious environment, organizations continuously seek opportunities to reduce administrative costs. Furthermore, as SONs strive to produce enough graduate nurses to reduce the nursing shortage, the demand for quality-precepted clinical placements has increased. Therefore, the opportunity to collaborate in novel practice environments is not only mutually beneficial but potentially addresses areas of learning and competence where new graduates struggle.


The first phase of this educational pilot project began after receiving exempt status from the UTMB Institutional Review Board. It included a three-phase intensive training lab for all 123 capstone students. Phase 1 included classroom/computer laboratory exposure in an EPIC (© 2020 Epic Systems Corporation Electronic Health Record) EHR training environment led by a hospital employee who also has a joint appointment to the SON. Here, students navigated the patient EHR training environment in a guided, risk-free manner to familiarize themselves with the EHR platform and executional functions of the program. Training included a systematic review of what areas of the medical record to access, an itemized list of criteria to look for within the record, and how to record discrepancies or inconsistencies with accrediting standards for data collection purposes.

Phase 2 involved participation by small groups of students conducting environmental scans in simulated patient care areas under the guidance of an experienced RN quality auditor. Multiple staged areas included patient simulation rooms and the nurse’s station in the simulation lab with various safety issues and other violations of standards. This exercise provided students an opportunity to practice identifying environmental issues. The auditors used standardized templates to ensure identification of all planted infractions by the student groups before moving on to the next scenario.

Phase 3 of the pilot, consisting of practical application of the learning activity in the actual patient care environment, was voluntary. Because of the importance of maintaining strict adherence to HIPAA and ensuring a high level of quality control, only students who volunteered were permitted to participate in live chart reviews and environmental scans in the hospital setting. It was assumed that students who volunteered would value the opportunity and perform at a higher standard than others. Limiting the practical experience to a small group allowed for oversight of the students’ work product and accountability of the quality improvement team.


All 123 students enrolled in the capstone course successfully completed Phases 1 and 2 of the initiative; 19 students participated in Phase 3 of the educational activity by completing either EOCs, POCs, or both during the seven-week course. Eight students completed up to 12 EOCs each for a total of 74; 18 completed up to 12 POCs each, for a total of 193. The students earned approximately 270 hours of clinical time for this endeavor. Although the number of person-hours is not an exact equivalent, as students are learning and require expert oversight and guidance, estimates support that student participation assisted the Quality Department to complete an entire quarter’s worth of EOC and POC audits in a seven-week period, saving the department a considerable number of person-hours by offsetting professional nursing time required to complete these auditing tasks.

Feedback collected from students was overwhelmingly positive and included appreciation for the opportunity to participate in thoughtful reflections regarding their own practice, documentation, and being more cognizant of the review process. Graduates from the SON who are hired to work at the facility participate in a nurse residency program for up to one year. During a regularly scheduled monthly meeting of the nurse residents, graduates who participated in the project were invited to share their feedback in a focus group. Follow-up was done with 10 participants who, coincidentally, experienced an accreditation site visit during their first year of employment as a nurse.

These graduate nurses engaged in dialogue about their experience in the training as well as during the accreditation site visit. They reported “feeling more comfortable than [peers] who did not participate in the training,” “knowledgeable about the process, so I wasn’t afraid when they [accreditors] were on the unit,” and “overall, glad we had the training and knew what to expect.” The one negative comment was, “I wish I had really known how important all this was when I was in school. I did not realize how quickly it would affect me.”


Anecdotally, we know from the science of learning and development that exposure and opportunity to observe practice facilitates student learning (Darling-Hammond et al., 2019). By creating partnerships between the Health System and the SON, whereby students become active members of the health care team while also learning and reinforcing the skills of the profession, the SON can produce graduate nurses who are better prepared for practice upon graduation. One part of that practice readiness is preparing graduate nurses who are more knowledgeable about the accreditation process and embrace the practice of continuous compliance. We hypothesize that this leads to fewer new staff nurses feeling intimidated by health system auditors or site visits by representatives from accrediting bodies. Recent graduates of the nurse residency program support this supposition.

Nursing education must adapt as the increased demand for improving the quality and safety of patient care rests primarily on the shoulders of RNs. Preparation of graduate nurses to respond to the increasing complexities of health systems and regulations being driven by health care reform promote readiness for the transition from student to professional nurse (Ellerbe & Regen, 2012).


Darling-Hammond L., Flook L., Cook-Harvey C., Barron B., Osher D. (2019). Implications for educational practice of the science of learning and development. Applied Developmental Science. 10.1080/10888691.2018.1537791
Ellerbe S., Regen D. (2012). Responding to health care reform by addressing the Institute of Medicine report on the future of nursing. Nursing Administration Quarterly, 36(3), 210–216. https://doi.10.1097/NAQ.0b013e318258bfa7
Hofler L., Thomas K. (2016). Transition of new graduate nurses to the workforce: Challenges and solutions in the changing health care environment. North Carolina Medical Journal, 77(2), 133–136. 10.18043/ncm.77.2.133
Joint Commission, The. (2019). Standards manual content: Hospital accreditation. The Joint Commission E-dition.
Manzo B. F., Ribeiro H. C. T. C., Brito M. J. M., Alves M. (2012). Nursing in the hospital accreditation process: Practice and implications in the work quotidian. Revista Latino-Americana de Enfermagem, 20(1), 151–158. 10.1590/S0104-11692012000100020

Accreditation Preparation; Education Strategies; Graduate Nurse Experience; Learning Collaboration; Nursing Student Transition to Practice

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