Preparing for a Joint Commission survey can be challenging. Your hospital must:
- Know the standards
- Examine your current processes
- Improve areas that are not currently in compliance
You must be in compliance with the standards for at least four months prior to your initial survey. For resurveys, we require a 12-month "track record" of standards implementation. However, we expect you to be in compliance with applicable standards during your entire period of accreditation, so surveyors will look for a full three years of implementation for several standards-related issues, including performance improvement activities.
For an initial survey, allow 9-12 months of preparation before your survey date. You'll have sufficient time to:
- Review the standards carefully
- Conduct an organizational self-assessment
- Take measures to improve where needed
- Develop new policies or processes
- Conduct staff training
The following checklist can help you prepare for an initial or triennial survey.
- Read all the information in the Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH). This manual includes all the hospital standards as well as a section covering official Joint Commission accreditation policies and procedures. Read all the standards and determine their relevance to your hospital. Remember that you are responsible for items in the intent statements as well as in the standards; be sure to read the scoring guidelines. Surveyors will look for multidisciplinary or organizationwide approaches to the standards, so don't limit your compliance to specific departments or disciplines. The examples of implementation and the scoring guidelines can help you understand the meaning of the standards and intent statements.
- Attend seminars to help you understand the standards. Besides the many seminars that we sponsor throughout the year, state hospital associations and other professional associations often give presentations on Joint Commission standards. Read some of the many publications and other resources on hospital standards and related topics. For answers to questions about a specific standard, call the Department of Standards at 630-792-5900.
- Network with colleagues from hospitals that have recently gone through the accreditation process. Attend professional association meetings or call your counterparts in other organizations. Online bulletin boards sponsored by professional associations can be particularly helpful.
- Ensure that staff understand how to comply with the standards. Develop programs to educate staff about new systems. The surveyors will interview staff members to see how well they understand your processes.
- Use the scoring guidelines in the AMCAH to conduct a mock survey. Document any areas of partial compliance and noncompliance that you identify. Mock surveys are most helpful when conducted regularly throughout the accreditation cycle. Regular mock surveys help you judge your hospital's efforts at continuously improving performance and help you fix problems before surveyors arrive. Some organizations hire consultants to conduct mock surveys if they don't have the time or expertise to do it themselves.
- Review the results of your mock survey with your staff. Develop a plan to correct the problems you found and set priorities for improvement. Establish a realistic schedule for improvements. We offer several tools to assist you: (see jcrinc.com)
- 2006 Compliance Assessment Checklist for Hospitals
- 2006 Accreditation Process Guide for Hospitals
- Tracer Methodology: Tips and Strategies for Continuous Systems Improvement
- The Joint Commission's Unannounced Survey Process
- Immediately before your survey, meet with your staff to review expectations and relieve anxiety. Reviewing what will happen during the survey will help boost staff confidence and help your people relax.
The best way to prepare for a survey is to incorporate the standards requirements into your daily activities. By continuously improving your hospital's processes, you can improve existing methods and correct problems before they become serious.