The Joint Commission’s Early Survey Policy allows health care organizations to undergo a survey prior to having the ability to demonstrate full compliance with all Joint Commission standards, and receive a preliminary accreditation decision. Surveys conducted under the Early Survey Policy are announced. Early surveys require an organization to undergo two on-site surveys. The early survey option is available for:
- New organizations before they begin operations.
- Organizations that are being surveyed by The Joint Commission for the first time.
- Organizations that have not participated in the accreditation process during the previous two years.
- Organizations that were denied accreditation during the previous two years.
To initiate an early survey, the organization submits an application for survey and indicates that it wishes to be surveyed under the early survey option. Laboratories have an additional Early Survey Option 2 available, due to the track record requirement (see below for more information).
The First Survey
For new organizations, the first survey may be conducted as early as two months prior to the organization becoming operational (i.e., when the organization begins to provide care to at least one patient, resident or client), provided it meets the following criteria.
- It is licensed or has a provisional license, according to applicable law and regulation.
- The building in which the services will be offered or from which the services will be coordinated is identified, constructed and equipped to support such services.
- It has identified its chief executive office or administrator, its director of clinical or medical affairs, its nurse executive, if applicable, and its director of clinical services.
- It has identified the date it will begin operations.
The first survey usually lasts two days. Survey length and the number and types of surveyors vary depending on the type of organization and the specific standards to be assessed. Generally, a limited set of standards is used and only the organization’s physical facilities, policies and procedures, plans and related structural considerations are assessed.
If the organization is in compliance with the limited set of standards used, the organization receives preliminary accreditation. If the organization fails the first survey, it must reapply to begin the accreditation process again. If the organization meets the decision rules for conditional accreditation, it receives preliminary accreditation. If an organization is operating at the time of survey, the effective date for its Preliminary Accreditation is the day after the survey is conducted if the organization does not receive any Requirements for Improvement. If the organization receives at least one RFI and therefore must submit an acceptable Evidence of Standards Compliance report that resolves all RFIs, the effective date for Preliminary Accreditation is the date of the acceptable ESC submission.
For an organization not operating at the time of the survey, the effective date for its Preliminary Accreditation decision is the day after it begins operating if the organization does not receive any RFIs. If the organization receives at least one RFI and therefore must submit an acceptable ESC report that resolves all RFIs, the effective date for Preliminary Accreditation is then set retroactively as the date of the acceptable ESC submission.
The designation of preliminary accreditation for hospitals or home care organizations does not deem the organization eligible to participate in the Medicare program. The organization remains in preliminary accreditation until a decision based on a second full survey is reached. Meanwhile, anyone who requests information about the organization’s status will be informed of the preliminary accreditation status—and that is all. No Quality Report is generated until the final accreditation decision is awarded, following the second survey.
The Second Survey
The organization’s second survey, a full survey, is conducted on-site approximately six months after the organization’s first survey, but at least four months after the organization has begun operation. Following the second survey, the organization’s accreditation status is changed to accredited, conditional accreditation, or preliminary denial of accreditation, in accordance with applicable aggregation and decision rules. The organization’s three-year accreditation cycle is based on the date that their successful Evidence of Standards Compliance (ESC) is submitted, provided that this survey did not result in denial of accreditation.
Survey fees for the first survey are the base rate for the relevant accreditation program. For the second survey, the fee is the program’s base rate plus an encounter fee based on projected annual patient volume. The Joint Commission may withdraw preliminary accreditation:
- When an organization that was not providing services at the time of the first survey does not begin services when expected;
- If an organization does not continue to meet the survey eligibility criteria;
- If an organization fails to accept the date of the second survey; or
- If an organization is found not in compliance with the applicable standards and their elements of performance.
Early Survey Option 2 for Laboratories
Laboratories have an additional Early Survey Policy Option 2 available to them. Early Survey Option 2 allows a laboratory to receive provisional accreditation (including a requirement for improvement for insufficient track record of compliance), conditional accreditation, or preliminary denial of accreditation. The laboratory undergoes two surveys, as under Option 1; however, the initial survey is a full accreditation survey, rather than a survey against a limited set of standards. Option 2 is available to:
- New laboratories that were denied accreditation during the previous two years.
- Laboratories that have never been surveyed by The Joint Commission.
- Laboratories that have been in actual operation for at least one month and have provided care for at least 10 patients, with at least one patient in active treatment at the time of survey.
- Laboratories that were not denied participation in the Medicare program as a result of a survey conducted or action taken by the Centers for Medicare & Medicaid Services or the state on behalf of CMS.
Option 2—The First Survey
Unlike Option 1, depending on a laboratory’s level of standards compliance, a laboratory may either receive accreditation, conditional accreditation or preliminary denial of accreditation. The requirement for improvement would relate, at a minimum, to limited or absent track records of performance in the functional areas where these are required. The effective date of the accreditation decision is the day after the first survey if the laboratory does not receive any RFIs. If the laboratory receives at least one RFI and therefore must submit an acceptable Evidence of Standards Compliance report that resolves all RFIs, the effective date of the accreditation decision is the date of the acceptable ESC submission. The results of the first survey are subject to public release. A Quality Report, which includes organization-specific performance data, is generated when the results of the first survey are completed.
Option 2—The Second Survey
The laboratory undergoes a follow-up survey about four months later to address the track record requirements that could not be assessed during the first survey due to the limited time of operation. Any requirements for improvement resulting from the initial survey are assessed. Particular attention is also given to the issue of sustained performance since the first survey. Following the second survey, the laboratory’s accreditation status may change to accredited, provisional accreditation, conditional accreditation or preliminary denial of accreditation. The effective date of this decision is based on the date the successful ESC is submitted. Other follow-up activities may be required based on the survey findings from either of the two surveys.
For more information, call Gail Weinberger, director of policy and administration, at (630) 792-5766.