Joint Commission Overview

  • 21 Aug 2018 4:05 PM
    Message # 6632760

    I am relatively new to my position and am finding Joint Commission a bit over whelming.  Is there a condensed overview of volunteer guidelines anywhere that I can reference?  We are preparing for our annual meeting and need to make sure we are not over looking any requirements.  Thanks in advance for any assistance.   

  • 22 Aug 2018 9:35 AM
    Reply # 6633847 on 6632760

    I've been a DVS for 20+ years and have only had involvement with TJC three times -  all related to HOW volunteers are oriented and trained. At that time, they seem particularly interested in fire safety and infection control procedures and training, including ongoing training and forms of communication. And, it was just announced about 12 minutes ago that TJC just walked in the door of my hospital - as I type this they are here. I have not had ANY involvement from TJC in the past 16 years, and I doubt they will ask for me today. I've heard other colleagues say they have recently (past 2-3 years) been interested in seeing Pet Therapy dog vaccine and rabies records, so I have mine in order, but they did not even mention it on our last survey. Make sure you have your volunteer files in order, signed confidentiality statements, signed position descriptions, documentation that all volunteers completed mandatory education when they onboarded and each year during the annual review. A surveyor once asked me if I complete an annual review/observation on each volunteer (I have over 700) and I stated that volunteers are observed on a daily basis each time they are here; should an exception to SOP occur, there is a review and follow up done at that no, I don't do formal reviews/observations on over 700 volunteers. I hope this is of some help to you.

  • 28 Aug 2018 6:21 PM
    Reply # 6643457 on 6632760
    Jenelen Dulemba (Administrator)

    I also have been a DVS for over 20 years and have had interaction with TJC with almost every visit.  However, never has it been a negative interaction.  The last 2 or 3 visits I have been asked to be present at a large group meeting where the surveyor asks questions of individuals as we introduce ourselves.  Additionally, I have had individual meetings with the surveyor (always someone from Administration present) and review several volunteer files and explained our onboarding and training process.  I agree that most of my questions have been focused on initial and continuing training and education (once I was specifically asked about training concerning the reporting of abuse) and how we know individuals are competent.  We do self-reviews annually and, as Christine shared, do training/reassignment/"termination" based on exception whenever it occurs. 

    Feel free to contact me if you would like to talk. 

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