The Joint Commission survey process is data-driven, patient-centered and focused on evaluating actual care processes. The objectives of the survey are not only to evaluate the organization, but to provide education and “good practice” guidance that will help staff continually improve the organization’s performance. Joint Commission on-site surveys are designed to be organization-specific, consistent and to support the organization’s efforts to improve performance. Survey length is determined by information supplied on the application.
Unannounced surveys
Organizations receive no notice of the survey date prior to the start of the survey, unless it would not be logical or feasible to conduct an unannounced survey, such as with Department of Defense and Bureau of Prisons facilities and some very small organizations. An organization can have an unannounced survey between 18 and 39 months after its previous full survey (24 months for laboratories, which have their survey prior to when their accreditation expires). The date of the survey is based on pre-established criteria generated from Priority Focus Process data, as well as other factors.
The on-site visit
The survey agenda includes:\
- Survey planning session
- Opening conference and orientation to the organization
- Leadership session
- Tracer methodology. The cornerstone of The Joint Commission survey, the tracer methodology uses actual clients, patients or residents as the framework for assessing standards compliance.
- Individual tracers follow the experience of care for individuals through the entire health care process.
- System tracers evaluate the integration of related processes and the coordination and communication among disciplines and departments in those processes. The system tracers are specific time slots devoted to in-depth discussion and education regarding the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, and other current topics of interest to the organization.
- New in 2009, a Life Safety Code® specialist will be part of the survey for all hospitals, including critical access hospitals. The specialist evaluates specific environment of care and Life Safety Code criteria and educates the organization on opportunities for improvement.
- Human resources review
- Credentials review
- Exit conference. CEO and organization exit conferences are held to discuss survey findings with leadership and staff.
After the survey
Beginning in 2009, a “Summary of Survey Findings Report” will be left on-site. The report does not include the potential accreditation decision or “Supplemental” findings. Instead, the Official Survey Report
posted on the organization’s secure Joint Commission Connect extranet site will include the potential accreditation decision.
If an organization does not receive any requirements for improvement (RFIs), the organization’s accreditation decision is rendered at the same time that the organization’s Summary of Survey Findings Report is available, and is official the day after the completion of the survey.
If an organization receives requirements for improvement, then the organization’s accreditation decision is made after the submission of an acceptable evidence of standards compliance (ESC) report. The organization’s accreditation decision is retroactive to the day after the last day of the survey, unless it is the organization’s first Joint Commission survey. In that case, the effective date for accreditation is set retroactively as the date on which an acceptable ESC that resolves all RFIs submitted.
Quality Check®
When an organization’s accreditation decision becomes official, it is publicly disclosed. The decision will be posted to Quality Check® on The Joint Commission’s Web site within one business day of being posted to the extranet. Quality Check ― www.qualitycheck.org ― is a comprehensive guide to health care organizations in the United States.