Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. This visit is called a survey. All regular Joint Commission accreditation surveys are unannounced.
Joint Commission surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other health care professionals. The Joint Commission is the only health care accrediting body that requires its surveyors be certified.
During the survey, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care, and often speak to the patients themselves.
Joint Commission accreditation does not begin and end with the on-site survey. It is a continuous process. Every time a nurse double-checks a patient’s identification before administering a medication, every time a surgical team calls a" time out" to verify they agree they’re about to perform the correct procedure, at the correct site, on the correct patient, they live and breathe the accreditation process. Every three months, hospitals submit data to the Joint Commission on how they treat conditions such as heart attack care and pneumonia – data that is available to the public and updated quarterly on qualitycheck.org. Throughout the accreditation cycle, organizations are provided with a self-assessment scoring tool to help monitor their ongoing standards compliance. Joint Commission accreditation is woven into the fabric of a health care organization’s operations.