On-site Survey Process Fact Sheet
The on-site survey process is data-driven, focused on patient safety and quality, and evaluates actual care processes and technology. On-site surveys are designed to be organization-specific, consistent and to support the organization’s efforts to improve quality.
Survey length is determined by information supplied by organizations on their application. Objectives of the survey are to:
- Evaluate the organization using standards and elements of performance (for deemed organizations, many standards cross walk to the Centers for Medicare & Medicaid Services’ Conditions of Participation).
- Provide education and “good practice” guidance that will inspire staff to continually improve the organization’s performance.
Unannounced Surveys
An organization can have an unannounced survey between 30 to 36 months after its previous full survey (24 months for laboratories). Most organizations receive no notice of the survey date prior to the start of the survey, unless it would not be logical or feasible to conduct an unannounced survey, such as with Department of Defense facilities. Some organizations receive a seven-day notice because of size, caseload, surveyors needing advance security clearance, or if the survey is not a deemed event.
The survey agenda includes:
- Survey-planning session
- Opening conference and orientation to the organization
- Leadership session
- Tracer methodology using actual patients, residents or individuals served to assess standards compliance
- Individual tracers following the experience of care for individuals through the health care process, including safety culture assessment
- Performance improvement system tracer
- Competence assessment process
- Medical staff credentialing and privileging (hospitals only)
- Environment of care document review session, including a building tour
- Exit conference, including a written summary of the survey findings
After the survey
Shortly after the survey, an organization’s report of survey findings is posted on its secure Joint Commission Connect® extranet. If an organization does not receive any requirements for improvement (RFIs), the accreditation decision becomes official at the same time that the organization’s summary report is available and is effective the day after the completion of the survey. If an organization receives RFIs, the organization’s accreditation decision is made after the submission of an acceptable evidence of standards compliance (ESC) report.