In July 2007, The Joint Commission began conducting on-site validation surveys of a sample of those organizations that are required to submit Evidence of Standards Compliance (ESC). These ESC validation surveys will gradually replace the original random unannounced surveys of all accredited organizations. While the pool of organizations eligible for the original random unannounced surveys has progressively decreased since the advent of unannounced surveys in 2006, the pool of organizations eligible for ESC validation surveys progressively increased through 2007.
Evidence of standards compliance validation surveys
A 5 percent random sample of organizations required to submit an ESC, with or without Measures of Success (MOS), will be selected annually for an unannounced on-site ESC validation survey. The surveyor(s) conducting the validation survey will have access to the submitted ESC and MOS. The primary purpose of the survey is to validate the statements made in the ESC submissions by surveying the areas that were the subject of each Requirement for Improvement to determine whether the stated corrective actions were implemented as declared.
Organizations required to submit only an ESC would experience their validation surveys shortly after the acceptance of their ESC. Organizations required to submit both an ESC and an MOS would experience their validation surveys shortly after submission of the MOS. Most validation surveys will last one day, and all validation surveys will be unannounced. Organizations selected for an on-site validation survey will not be charged for the survey.
Random unannounced surveys
The Joint Commission conducts one-day unannounced surveys on a random sample of organizations in the ambulatory care, behavioral health care, home care, hospital and long term care accreditation programs. The surveys are conducted nine to 30 months following the accreditation date at no charge to the organization. During the survey, the surveyor assesses both fixed and variable components, or performance areas. The surveyor reviews all variable components identified for the organization and then, as time allows, addresses the fixed components. The survey may lead to RFIs that require follow-up in an ESC submission.
- Variable components of random unannounced surveys
Variable components are specific to the organization being surveyed. Presurvey information, such as previous recommendations, ORYX core measure data, demographic data related to clinical service groups and diagnostic-related groups, data from the Joint Commission’s Quality Monitoring System, and MedPar data (as applicable to the organization) is run through the Priority Focus Process to identify Priority Focus Areas.
- Fixed components of random unannounced surveys
Fixed components are identified each year based on the degree of actual or perceived risk to the care of patients and clients posed by noncompliance with standards related to critical performance areas. In 2007, the fixed components are the National Patient Safety Goals and the three most important PFAs for each accreditation program. By program, these are:
- Ambulatory Care
- Patient Safety
- Assessment and Care/Services
- Quality Improvement Expertise/Activities
- Behavioral Health Care
- Assessment and Care/Services
- Client Safety
- Medication Management
- Home Care
- Patient safety
- Assessment and Care/Services
- Quality Improvement Expertise/Activities
- Hospital
- Patient safety
- Medication management
- Assessment and Care/Services
- Long Term Care
- Resident safety
- Assessment and Care/Services
- Medication Management