The length of your survey will depend on the scope and volume of the services that your organization provides. The survey activities described here apply to all behavioral health care organizations.
Opening conference and organization overview
The survey begins with an opening conference on the morning of the first day. This conference will introduce the surveyor or survey team to your key staff, and review and confirm the tentative survey agenda. Your chief executive officer will determine which staff members should attend the conference, which is limited to 15 minutes.
Immediately after the opening conference, key members of your staff will present information about your organization's structure and scope of services. This presentation helps orient the surveyors to your organization and provides the foundation for all survey activities. The presentation is limited to 15 minutes.
Document and Record Review
Surveyors may review documentation, policies, and procedures throughout the survey to orient themselves to your organization and discover issues that they will look at more closely later in the survey. Surveyors will ask to see documents that show your organization's overall performance, including:
- committee minutes
- planning documents
- bylaws (if applicable)
- policies and procedures
- other evidence of performance
- reports of measurement and assessment activities
- reports to clinical staff, leaders, and the governance
The surveyors examine records to assess the planning and implementation of your environment of care management programs related to:
- committee minutes
- planning documents
- bylaws(if applicable)
- policies and procedures
- other evidence of performance
- reports of measurement and assessment activities
- reports to clinical staff, leaders, and the governance
The surveyors examine records to assess the planning and implementation of your environment of care management programs related to:
- life safety
- utility systems
Such documentation may include records of fire and emergency drills, equipment logs for routine and preventive maintenance, and so on. If your organizations qualifies as a residential occupancy, the surveyors will also examine your Statement of Conditions™.
The surveyors will review your credentials files and personnel records. They will examine the files of licensed independent practitioners and staff to look at orientation, training, continuing education, competence assessment, and credentials review (as appropriate).
The surveyors will review a sample of your clinical/case records to assess their integrity and usefulness as well as to verify compliance with specific individual-focused standards.
Program/Service visits
Each surveyor will visit care and program settings to see how you take care of the individuals served and how you have implemented and improved your planning, improvement, and design processes.
Each visit includes:
- a discussion with the supervisor of the program/service
- a tour of the site to survey the environment of care, infection control, consumer care, staff communication, consumer rights issues, and other standards
- conversations with direct care staff
- review of clinical/case records for selected consumers
- conversations with individuals served and/or families, as appropriate
- visits to foster homes for organizations providing foster care
Interviews
Surveyors will meet with leaders and direct care staff to determine each person's involvement in the operation of your organization and the provision of care. The surveyors will also interview staff who have important responsibilities for specific functions. During these interviews, surveyors can closely examine issues identified in document reviews and during prior survey activities.The interviews cover the following functions:
- improving organization performance
- information management
- infection control
- rights and ethics
- human resources
Public information interviews
A surveyor interviews anyone who has information about your organization and who has requested a public information interview. These sessions provide information about your organization's compliance with accreditation standards by interviewing a variety of individuals--including individuals served and families, referral sources, employees, and residents from the community.
Daily Briefings
The surveyors conduct a daily briefing with your CEO and other key management staff at the beginning of each survey day except the first. The briefing provides your organization with feedback about the previous day's activities and findings, allows staff to present information that the surveyors may have missed during the survey, and reviews the agenda for the day.
Leadership exit conference
The leadership exit conference is held on the last day of your survey. The surveyor(s) will give you a preliminary report, including a preliminary accreditation decision. The final decision is made at the Joint Commission's central office after we analyze the surveyors' written findings. However, during the conference you can discuss any findings you believe to be invalid, and present additional information that the surveyors may have overlooked.