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So, who is TJC anyway?

So, who is TJC Anyway?

If you’ve been in healthcare long enough, you’ve heard the dreaded words: TJC is coming. If you’ve been around for a really long time, you’ve probably even heard them referred to as JCAHO. Maybe you went along with the eye-rolls from your co-workers and noticed the look of distress from your manager but secretly wondered what the fuss was all about.

TJC is The Joint Commission, which is a governing body for hospitals. It’s a non-for-profit institution responsible for certifying healthcare businesses with a “gold seal of approval.” While TJC promises this may mean a market advantage compared to hospitals who are not certified, educational improvements, and lowered overall risk by promoting the best safety practices, most hospitals choose certification so insurers will pay the hospital for their procedures and care.

Essentially, hospitals and healthcare agencies need a compliance agency like The Joint Commission to certify them before they are eligible for Medicare reimbursement.


For some outpatient or ambulatory services, this certification process may not make much sense. Still, if you’ve looked around at your hospital patient base lately, you can see why having the ability to bill Medicare is really important.

So, yes, your hospital likely needs to do a TJC survey, which happens every three years. One week in the 3rd year, a bunch of nurses and doctors show up to perform a site visit. There may be widespread panic while your hospital tries to undo years of bad practices and prove they are safe for the aging population.

But it doesn’t have to be that way.


The whole point of TJC is to promote best practices. The organization’s goal is to promote safety and high-quality care, which is really what you are trying to give your patient anyway. The thing is, it’s hard to unlearn bad habits for surveys, so many hospitals learn the hard way what happens when safety doesn’t actually come first.

This isn’t TJC’s fault, but it’s easy to give the dreaded survey the blame. The truth of the matter is that this occurrence is often due to something called practice drift. Similar to a car drifting into the next lane, practice drift occurs when nurses figure out shortcuts or workarounds. It isn’t necessarily blatantly wrong practice, but it’s a little over the white line. For example, the nurse doesn’t swab the hub of an IV before every IVP medication or leaves some pills out for a patient to take after they get back from the bathroom. A little drift over the white line probably isn’t going to kill anyone, but if the driver never corrects the car back into the right lane, big problems might be headed your way.

TJC is like the police officer in the median. They find the drift, and it’s enough to strike fear into the hearts of nurses everywhere.


There are ways to prepare and it starts with you and your unit. It’s the small things that add up, like not washing your hands every time, meds in unsecured locations, or poor documentation. Start by looking at your processes. What steps are you skipping; where are you attempting to save time? If you aren’t sure what a process is supposed to look like, look it up!


All it takes is one person to identify drift to start the wheel back in the right direction. Stay in your lane and you won’t worry the next time TJC stops by.

Amanda Ernst, DNP, RN, CEN

Amanda Ernst, DNP, RN, CEN


Amanda is an ER nurse with 10 years of healthcare experience. She currently works as a nurse educator and as an adjunct professor for several schools. She also works as a freelance healthcare writer in her spare time. Amanda thinks the greatest thing about nursing is the endless possibilities and opportunities to learn. What have you learned today?


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