The Joint Commission creates a tailored survey if your organization provides services covered by standards in more than one of our accreditation programs:
A tailored survey covers the services your organization offers. If we'll survey your organization under more than one accreditation manual, you must comply with all applicable standards in each manual. Surveyors from each accreditation program will be part of your survey team.
For example:
Laboratory survey tailored with a hospital survey
A separate laboratory surveyor will survey all eligible laboratory services provided by the hospital, using the the laboratory survey process and standards in the Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services. This is a separate survey conducted on a two-year cycle.
Although you will receive a separate preliminary report from each applicable accreditation program, your organization will receive only one accreditation decision for all the services you provide. Your accreditation decision will be based on the worst accreditation results from each separate survey. For example, if your hospital-based home care organization was eligible for Accreditation Without Type I Recommendations (becomes Accreditation with Full Standards Compliance on Jan. 1, 2002), but the hospital’s survey resulted in Conditional Accreditation, your entire organization’s final decision would be Conditional Accreditation.
The Joint Commission will use an interim method for weighting survey results for organization components in the accreditation decisions of large, complex organizations surveyed after January 1, 2000. The interim method is intended to provide a large complex organization with an overall accreditation decision that reflects the performance of each of its components based on the size of the component. This change will diminish the impact that the poor performance of a single small component may have on the organization's overall decision. For any tailored survey, the Joint Commission will identify one program as "primary" (as is currently done), then determine the accreditation decision for the organization based on the following rules:
- If there are any type I recommendations in the primary or secondary (i.e., component) program of a complex organization, the highest accreditation decision possible for the organization is Accredited with Type I Recommendations (becomes Accreditation with Requirements for Improvement on Jan. 1, 2002).
- If the primary program meets rules for either Conditional Accreditation or Preliminary Denial of Accreditation, the decision for the organization will be the same.
- If one of the secondary programs meets rules for Preliminary Denial of Accreditation, the decision for the organization will be Conditional Accreditation.
- If one of the secondary programs meets rules for Conditional Accreditation, the decision for the organization will be Accredited with Type I Recommendations (becomes Accreditation with Requirements for Improvement on Jan. 1, 2002).
- If two or more of the secondary programs meet rules for Preliminary Denial of Accreditation, the decision for the organization will be Preliminary Denial of Accreditation.