Project REFRESH Debuts New Accreditation Survey Report - Jan. 1, 2018! | Joint Commission

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Project REFRESH Debuts New Accreditation Survey Report - Jan. 1, 2018!

Nov 15, 2017 | 7618 Views

Kay KruseBy Kay Kruse
Project Director, Business Transformation
Accreditation & Certification Operations

The Joint Commission’s Ambulatory Care customers told us their survey reports were often confusing to navigate. They asked us to redesign the survey report to make it more user-friendly and easier-to-understand. Our customers asked that the report highlight the most relevant information about their Ambulatory Care survey outcomes, and the required follow-up activities. Among other customer requests were:

  • prioritize and group survey findings by severity

  • highlight CMS Condition-Level and Standard-Level Findings

  • offer report sorting/filtering 

  • remove repetitive text

We’ve listened and – and through the ongoing efforts of Project REFRESH – will introduce a new accreditation survey report format that will be implemented for ambulatory care surveys conducted after Jan. 1, 2018.

Simplified Accreditation Survey Report 
The Joint Commission worked with Ambulatory Care Customer Advisory Groups, Ambulatory Care Surveyors and our Central Office staff to prepare a new Accreditation Survey Report. This new report will provide easy-to-read tables to succinctly deliver key information, in response to organizations’ request for simplicity. In addition to a PDF version, the new report will be provided in a downloadable Excel file.


The new survey report is organized into six sections, here are highlights from some of the new sections:

Cover Page
The cover page contains the name and address of the organization; the type of survey conducted, the programs surveyed (if applicable) and the organization’s on-site survey dates.

Executive Summary
This new portion of the survey report provides summary information by program, including:

  • programs surveyed and on-site survey dates

  • the accreditation decision

  • post-survey activity

  • follow-up time frames and submission due dates

What’s Next – Follow-Up Activity  
This new area displays each standard and Element of Performance (EP) with its required follow-up activity. Also included on this page are The Joint Commission and CMS Conditions for Coverage (CfCs) associated with the Requirements for Improvement (RFIs) contained in the report (as applicable for ambulatory surgery centers choosing Joint Commission’s deemed status option).

Survey Findings
The SAFER Matrix – which debuted earlier in 2017 – is included in this section. If the survey was conducted to satisfy CMS deeming requirements, a CMS summary table is provided. The standards and EPs are displayed alphabetically by chapter.  Multiple observations associated with a single EP are numbered.

Want to Learn More?
For questions regarding the new format for your Ambulatory Care Accreditation Survey Report, please contact Kay Kruse at

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