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Posted: September 6th, 2023

Create a flowchart to help visualize the process of Joint Commission accreditation

Please follow all the instructions APA 7 citations and reference

Create a flowchart to help visualize the process of Joint Commission accreditation

1. Learn about the accreditation process for Ambulatory Care and how the Joint Commission accredits.

• Ambulatory Care

2. Create a flowchart showing the process of Joint Commission accreditation for the type of facility you selected. Include pre-survey, survey, and post-survey steps in the process.

3. Word document, write an 8-10 sentence paragraph reflecting on HIM professionals’ roles and responsibilities in the Joint Commission accreditation process. For example, you might discuss:

Ø The points in the process where a Joint Commission surveyor/accreditor will need to see documents the HIM professional maintains.

Ø The types of documents the Joint Commission surveyor/accreditor might need to look at.

Ø What the HIM professional must do to be prepared for the Joint Commission accreditation process.

4. How do these standards affect the HIT department’s functions? Write an 8-10 sentence paragraph

Ø Documentation of Mandated Discharge Summary Components in Transitions from Acute to Subacute Care



The accreditation process for Ambulatory Care by the Joint Commission involves several steps. Ambulatory care refers to healthcare services provided on an outpatient basis, including clinics, surgical centers, and rehabilitation centers. The Joint Commission accredits healthcare organizations to ensure they meet certain quality and safety standards. To learn about the accreditation process for Ambulatory Care, you can visit the Joint Commission’s website at

[Please note that I am unable to create visual content like flowcharts, but I can describe the process for you]

The flowchart for the Joint Commission accreditation process for Ambulatory Care would typically involve the following steps:

Pre-survey preparation: The healthcare facility gathers relevant documents and prepares for the accreditation survey. This includes conducting self-assessments, reviewing policies and procedures, and ensuring compliance with standards.

Survey scheduling: The facility contacts the Joint Commission to schedule the on-site survey. The survey is typically conducted by a team of Joint Commission surveyors who are experts in the field.

Entrance conference: The surveyors meet with the facility’s leadership and key personnel to discuss the survey process, objectives, and expectations.

Survey activities: The surveyors conduct interviews, observe processes, and review documents to assess compliance with the Joint Commission’s standards. They may request to see specific documents maintained by HIM professionals, such as policies, procedures, patient records, incident reports, and quality improvement data.

Findings and recommendations: The surveyors provide feedback on their findings and identify areas for improvement. They may issue citations for non-compliance with standards and offer recommendations for corrective actions.

Post-survey activities: The facility develops and implements plans to address any identified deficiencies. The Joint Commission may require the submission of evidence of corrective actions.

Accreditation decision: The Joint Commission evaluates the facility’s compliance and determines whether accreditation will be granted. The decision is based on the survey findings, evidence of corrective actions, and overall adherence to the Joint Commission’s standards.

In the Joint Commission accreditation process, HIM professionals play a crucial role in ensuring compliance and providing necessary documentation. Throughout the process, there are specific points where Joint Commission surveyors/accreditors will need to see documents maintained by HIM professionals. For example, during the survey activities, the surveyors may request to review policies, procedures, patient records, incident reports, and quality improvement data. HIM professionals are responsible for maintaining these documents and ensuring they are accurate, complete, and readily accessible.

To be prepared for the Joint Commission accreditation process, HIM professionals must:

Stay updated on the current accreditation standards and requirements set by the Joint Commission.
Establish and maintain robust documentation practices, including policies and procedures for recordkeeping and documentation management.
Conduct regular audits and reviews to ensure compliance with the Joint Commission’s standards.
Collaborate with other departments to gather necessary documentation and evidence of compliance.
Train and educate staff members on proper documentation practices and the importance of adherence to standards.
Participate in the development and implementation of corrective action plans following the survey findings.
Serve as a resource for the facility during the survey process, providing guidance and support to ensure accurate documentation is presented to the surveyors.
By fulfilling these roles and responsibilities, HIM professionals contribute to the overall success of the Joint Commission accreditation process and help ensure that the healthcare facility maintains high standards of quality and safety.

The Joint Commission standards have a significant impact on the functions of the Health Information Technology (HIT) department. These standards guide the HIT department’s activities related to documentation of mandated discharge summary components in transitions from acute to subacute care.
The HIT department plays a crucial role in supporting compliance with

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