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On-site Survey Process

  • 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 and safety on their journey to achieve zero harm.

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.

Note about the coronavirus pandemic and modified on-site surveys: As of June 2020, the on-site survey process is modified to employ physical distancing practices to ensure the safety of all parties during the COVID-19 pandemic. For example, while on-site, surveyors are required to use masks and/or other personal protective equipment (PPE) when required by the organization; maximize the use of technology; and limit the number of individuals in group sessions.

Unannounced Surveys

An organization can have an unannounced survey between 18 and 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 or surveyors needing advance security clearance.

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
  • System tracers evaluating the integration of related processes and the coordination and communication among disciplines and departments
  • Competence assessment process
  • Medical staff credentialing and privileging (hospitals only) and optional medical staff session
  • Environment of care 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. An organization’s official accreditation decision is publicly posted to the Quality Check® website within one business day of being posted to the extranet.

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