The Joint Commission conducts unannounced surveys:
- To help health care organizations focus on providing safe, high quality care at all times.
- To affirm the expectation of continuous standards compliance both by The Joint Commission of its accredited organizations and by these organizations of themselves.
- To enhance the credibility of the accreditation process by ensuring that surveyors observe organization performance under normal circumstances.
- To reduce the unnecessary costs that health care organizations incur to prepare for survey.
- To address public concerns that The Joint Commission receive an accurate reflection of the quality and safety of care.
An organization will undergo an unannounced survey between 18-39 months after its previous unannounced survey. The timing of the survey is based on pre-established criteria generated from Priority Focus Process data, as well as other factors.
On the morning of an organization’s survey, the biographies and pictures of the surveyors assigned to conduct the survey will be posted to the organization’s secure site on the Joint Commission’s extranet, Joint Commission Connect. In addition, the organization’s Priority Focus Process summary report and the survey agenda will also be posted there.
Exceptions to unannounced surveys
The following surveys are not conducted unannounced:
- Initial surveys (organizations undergoing their first Joint Commission survey)*
- First surveys for organizations that choose the Early Survey Policy option
- Periodic Performance Review Option 2 and Option 3 surveys
*All hospital and Centers for Medicare & Medicaid deeming or recognition surveys are unannounced.
A seven-day notice is given for the following surveys:
Ambulatory care program
- Ambulatory health care organizations that only provide medical/dental services and have fewer than 5,000 annual visits or less than three licensed independent practitioners
- Ambulatory health care organizations that provide specified diagnostic and therapeutic services and have fewer than 3,000 annual visits or four or fewer licensed independent practitioners
- Office-based surgical practices
- Organizations that provide mobile diagnostic services
- Organizations that provide non-deemed ambulatory surgery
- Telehealth organizations
- Sleep centers
Behavioral health care program
- Community-based, freestanding programs
- Foster Care programs
- Freestanding organizations with 10 or fewer staff or a total average daily census of less than 100
- In-home behavioral health, case management or Assertive Community Treatment program, if not part of a hospital
- Methadone programs, if not part of a hospital
Disease-Specific care certification program
- All disease-specific care reviews
Health Care Staffing certification program
- Health care staffing organizations with two or fewer full-time employees
Home care program
- Small, non-deemed health and hospice organizations, if not part of a hospital
- Small home care organizations that provide only one service
Laboratory program
- Small laboratories with fewer than 5,000 tests per year
Medicare/Medicaid certification-based long term care program
- One-day freestanding Medicare/Medicaid certification-based long term care surveys, if not part of a hospital
Other facilities
- Department of Defense facilities
- Bureau of Prison facilities
- Immigrant facilities
Accredited organizations can identify up to 10 days in which an unannounced survey should be avoided (i.e., black-out dates). These 10 days should not include federal holidays, but may include regional events in which it may be difficult to conduct a survey during a given period. The Joint Commission will make every effort to accommodate the organization’s request, but reserves the right to conduct a survey during an “avoid period” if the reason given to avoid a survey is such that a survey can be reasonably accomplished.
More information about unannounced surveys is available on this Web site. Accredited organizations may visit the Joint Commission extranet, Joint Commission Connect, or contact their account representative for additional information.
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