The purpose of a Joint Commission accreditation survey is to assess the extent of an organization's compliance with applicable Joint Commission standards. Organizations undergoing their first survey need to demonstrate a track record of four months of compliance with the standards. Organizations being resurveyed need to demonstrate twelve months of compliance with the standards. Understanding the organization and assessing compliance is accomplished through a number of methods including the following:
- receipt of verbal information concerning implementation of standards, or examples of their implementation, enabling analysis of compliance;
- on-site observation by Joint Commission surveyor(s); and
- review of documents that demonstrate compliance and assist in orienting surveyor(s) to the organization's operation.
Priority Focus Process
Priority Focus is a component of the on-site survey process that will allow surveyors to customize the survey process to each organization. The on-site survey agenda is developed based on information gathered about the organization from several sources, and is structured to spend more time on areas that have been challenges for the organization in the past. Organizations will find the Priority Focus Process to be information driven, and to be focused on their specific performance.
Data sources that will contribute to the Priority Focus Process include:
- Previous requirements for improvement from past surveys
- Plan of Action from the Periodic Performance Review
- Data from the completed Application for Accreditation
- Complaints about the organization (if any) received by the Joint Commission's Office of Quality Monitoring
(Priority focus for initial organizations is done, although the data set from which to pull information is limited.)
Tracer Methodology
Tracer Methodology is another component of the on-site survey that makes the client care experience the 'table of contents' to assess standards compliance. The surveyor(s) will select clients from an active client list to 'trace' their experience throughout the organization.
The surveyor(s) will follow the client's experience of care, treatment and services. This type of review is designed to uncover systems issues, looking at both the individual components of an organization, and how the components interact to provide safe and quality client care.
The number of clients followed under the Tracer Methodology will depend on the size and complexity of the organization, and the length of the on-site survey.
Evidence of Standards Compliance (ESC)
A final report is left with the organization at the end of the on-site survey that identifies any standards that were scored as partial or non-compliant. For those standards scored as partial or non-compliant, the organization submits Evidence of Standards Compliance to the Joint Commission within 90 days of the completion of the survey. Evidence of Standards Compliance would include quantifiable measures of success for all partial or non-compliant standards that the organization is committed to meeting within six months. The Evidence of Standards Compliance is approved by the Joint Commission, and the organization submits data at the end of six months to show that it has reached full compliance with the standards.
Periodic Performance Review (PPR)
Beginning with resurveys scheduled in July 2005, organizations will be required to complete a self-assessment process, called the Periodic Performance Review (PPR). Fifteen months after the completion of its last on-site survey an organization will receive an electronic self-assessment template to assist in the Periodic Performance Review. The organization will have three months in which to complete the assessment and return information to the Joint Commission.
The Periodic Performance Review will be required for organizations scheduled for resurvey beginning in July 2005 only.
The Periodic Performance Review process requires organizations to review all applicable standards and Accreditation Participation Requirements from the standards manual, and the National Patient Safety Goals. Completion of the assessment portion of the Periodic Performance Review will allow an organization to identify areas where it may not be in compliance with standards. The goal of a Periodic Performance Review is to help organizations identify performance areas out of compliance, and to guide them along the road to correcting these non-compliant areas before the next on-site survey.
For those areas self-identified as out of compliance with Joint Commission standards, the organization will submit a Plan of Action to the Joint Commission. The Joint Commission staff will review each organization's Plan of Action in a telephone interview and indicate whether the action plans and timetables are acceptable and meet the intent of the standards. Once the Plan of Action is approved by Joint Commission staff, the plan is filed with the organization's information, and will become part of the information set used to plan the next on-site survey.