Clarification Observers Standard

Effective in July 2017, The Joint Commission has updated the definition of an observer to qualify the role of surveyor/reviewer management staff during on-site surveys and reviews. The updated definition is reflected in new language for Accreditation Participation Requirement APR.07.01.01 and Certification Participation Requirement CPR 10. As the new language shows (see box below; new text is underlined), management staff will only participate in the survey process if they feel it is necessary to bring any potential findings or observations to the attention of the surveyor and the organization. These observers will not otherwise participate in the on-site survey process (including the scoring of standards compliance). It should be noted that field directors observing surveys and reviews are not included in the definition of observer as it appears in APR.07.01.01 and CPR 10. Field directors do participate in the survey and review process by providing surveyors/reviewers and organizations with observations for scoring standards compliance. Field directors’ participation helps surveyors and reviewers highlight opportunities for the organization to address during survey/review and provides additional risk identification that could otherwise be missed. The new language will be posted on the Joint Commission Standards page and published in the spring 2017 E-dition (scheduled to release in May) for all programs. Questions may be directed to your organization’s assigned account executive.

Effective July 1 2017
*Applicable to All Accreditation Programs

Accreditation Participation Requirements (APR)

Accreditation Participation Requirement APR.07.01.01
The organization accepts the presence of Joint Commission surveyor management staff or a Board of Commissioners member in the role of observer of an on-site survey.

Element of Performance for APR.07.01.01

  1. The organization allows Joint Commission surveyor management staff or a member of the Board of Commissioners to observe the on-site survey.
    Note 1: The observer will not participate in the on-site survey process, including the scoring of standards compliance. Surveyor management staff will only participate in the survey process if he or she feels it is necessary to bring any potential findings or observations to the attention of the surveyor and the organization.
    Note 2: The organization will not incur any additional survey fees because an observer(s) is present.

*Applicable to All Certification Programs Except Patient Blood Management

Certification Participation Requirements (CPR)

Certification Participation Requirement CPR 10
The organization accepts the presence of Joint Commission reviewer management staff or a Board of Commissioners member in the role of observer of an on-site review.

Element of Performance for CPR 10

  1. The organization allows Joint Commission reviewer management staff or a member of the Board of Commissioners to observe the on-site review.
    Note 1: The observer will not participate in the on-site review process, including the scoring of standards compliance. Reviewer management staff will only participate in the review process if he or she feels it is necessary to bring any potential findings or observations to the attention of the reviewer and the organization.
    Note 2: The organization will not incur any additional fees because an observer(s) is present.

Applicable to Patient Blood Management

Certification Participation Requirements (CPR)

Certification Participation Requirement CPR 10
The organization accepts the presence of Joint Commission – or AABB-approved observers on an on-site review. Element of Performance for CPR 10

  1. The organization allows Joint Commission – reviewer management staff or AABB-approved observers on an on-site review.
    Note 1: The observer will not participate in the on-site review process, including the scoring of standards compliance. Reviewer management staff will only participate in the review process if he or she feels it is necessary to bring any potential findings or observations to the attention of the reviewer and the organization.
    Note 2: The organization will not incur any additional fees because an observer(s) is present.