The Joint Commission conducts unannounced surveys:
- To help health care organizations focus on providing safe, high quality care at all times, and not just when preparing for survey.
- To affirm the expectation of continuous standards compliance both by The Joint Commission of its accredited organizations and by these organizations of themselves.
- To enhance the credibility of the accreditation process by ensuring that surveyors observe organization performance under normal circumstances.
- To reduce the unnecessary costs that health care organizations incur to prepare for survey.
- To address public concerns that The Joint Commission receive an accurate reflection of the quality and safety of care.
Organizations due for survey between 2006 and 2008 will have their unannounced survey in the year that the organization is due for survey. Beginning with the cohort of organizations due for survey in 2009, organizations will have their unannounced survey between 18-39 months after the organization’s first unannounced survey. The time of this latter survey and all succeeding unannounced surveys will be based on pre-established criteria generated from Priority Focus Process data, as well as other factors.
On the morning of an organization’s survey, the biographies and pictures of the surveyors assigned to conduct the survey will be posted to the organization’s secure site on the Joint Commission’s extranet, Joint Commission Connect. In addition, the organization’s Priority Focus Process summary report and the survey agenda will also be posted there.
Exceptions to unannounced surveys
The following surveys are not conducted unannounced:
- Initial surveys (organizations undergoing their first Joint Commission survey)*
- First surveys for organizations that choose the Early Survey Policy option
- Periodic Performance Review Option 2 and Option 3 surveys
*All hospital and Centers for Medicare & Medicaid deeming or recognition surveys are unannounced.
A five-day notice is given for the following surveys:
- Department of Defense facilities
- Bureau of Prison facilities
- “Small” laboratories
- Foster Care Programs
- Health care staffing organizations with two or fewer full-time employees
Immigrant facilities
- Ambulatory health care organizations that provide specified diagnostic and therapeutic services and have fewer than 3,000 annual visits or four or fewer licensed independent practitioners
- Ambulatory health care organizations that provide mobile diagnostic services
- “Small” home care organizations that provide only one service
- Disease-Specific Care reviews (excludes organ transplant, Ventricular Assist Device and Lung Volume Reduction Surgery reviews)
Accredited organizations can identify up to 10 days in which an unannounced survey should be avoided (i.e., black-out dates). These 10 days shouldn’t include federal holidays, but may include regional events in which it may be difficult to conduct a survey during a given period. The Joint Commission will make every effort to accommodate the organization’s request, but reserves the right to conduct a survey during an “avoid period” if the reason given to avoid a survey is such that a survey can be reasonably accomplished.
For more information, visit The Joint Commission website at www.jointcommission.org. Accredited organizations may visit the Joint Commission extranet, The Joint Commission Connect, or contact their account representative for additional information.
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