Gina Zimmermann is executive director of Nursing Care Center Services at The Joint Commission. In her role, she oversees the strategic direction and performance of the Commission’s Nursing Care Center Accreditation Program.

“It’s not often that The Joint Commission receives an opportunity to accredit a large portion of an organization’s full suite of sites,” Zimmermann says. Because Consulate wanted to bring all of its Florida care centers into the accreditation process within a very short period of time, it required more work to coordinate various aspects of the survey process.

This included making certain The Joint Commission’s internal operations, Consulate’s involved leadership, and the nursing centers were all in step with various milestones and events that are involved throughout the process.

Tracing an Experience

The accreditation survey involves on-site observations and interviews conducted by Joint Commission surveyors, review of documents provided by the organization, and assessment of the physical center.

“Much of the survey involves ‘tracing’ the patient or resident experience within the nursing home—looking at services provided by various care providers and departments within the organization as well as hand-offs between them,” says Zimmermann.

Throughout the survey, Zimmermann says, the surveyors focus on making the survey experience a collaborative one, to help the nursing center come into compliance with standards. Once the on-site survey is reviewed and accepted by Joint Commission staff, the nursing center is accredited.

Mobilizing a Company

What stands out about Consulate’s experience was its ability to mobilize quickly, says Zimmermann. “Consulate was able to mobilize leadership and staff across the entire Florida division to become accredited during a relatively short period of time—essentially within about nine months,” she says.

Much of the success had to do with Consulate’s leadership, which was able to articulate a goal and the strategy to achieve that goal.

“It is not easy to open yourself to scrutiny by an outside party,” Zimmermann says. “But all Consulate centers eagerly participated in the process and viewed it as what it is—an opportunity to learn from Joint Commission performance improvement experts how to proactively identify and address vulnerabilities in quality and safety to safeguard patients and residents.”

Not only did Consulate follow through on its vision and strategy, but staff exhibited passion, Zimmermann says. “This is evident throughout their organization, from leadership at the corporate level all the way through to individual care center leadership and frontline caregivers and staff,” she says.

But perhaps the most important part of it all comes after the accreditation decision has been awarded. “Then, it is up to the nursing center to maintain systems and processes required by the standards, and most importantly, sustain the improvements they have put in place,” she says.

Accreditation surveys occur every three years.