Prepare for a Joint Commission Survey: Tips to Stay Ahead

Healthcare facilities are held to a high standard when it comes to quality-of-care guidelines and regulations—and for a good reason. When lives are at stake, cutting corners simply isn’t an option. But these facilities have so many moving pieces, and patients often encounter different care providers and processes.

To ensure these processes are working according to plan and patient safety remains the priority, hospitals and other facilities are accredited by The Joint Commission, a regulatory nonprofit that sets standards and evaluates healthcare organizations in the United States.

In order to receive accreditation, hospitals get an onsite visit from The Joint Commission every three years. This process, known as a survey, can be an intimidating time—but just like with any other regulatory visit, the trick is planning ahead. In this article, we break down what to expect from a Joint Commission survey and how to prepare your facility and team.

What to Expect From a Joint Commission Survey

Joint Commission surveys are extensive affairs where the surveyors assess the quality of care your facility provides and whether your hospital meets the accreditation standards. Luckily, there are documents that cover what to expect. You can find a full breakdown of the Joint Commission survey schedule on their website that goes step by step through the full survey, as well as the E-dition (online manual) with info about accreditation requirements and standards your facility will be expected to meet.

What does a Joint Commission survey process look like?

Once the surveyors arrive, you’ll have some time (usually 30–60 minutes) to prepare for the actual onsite survey—gathering all your required documentation and informing your staff of the survey and what is expected of them. There will also be a series of briefings and conferences that cover safety procedures and general orientation and introduction.

Then comes the individual patient tracer, where surveyors follow a patient through every step in their care process, assessing the quality of patient care, checking for safety issues or medical errors, determining healthcare professionals’ competency, and doing a comprehensive review of health outcomes. The trace will involve looking through medical records and interviewing care providers and any staff involved in the care for that patient.

After the individual tracer, there will be a series of different meetings, observations, interviews, reviews, and tracers covering things such as:

• Competence assessment
• Medical staff credentialing & privileging
• Emergency management
• System tracer—data management, infection control, and medication management

Each of these activities will take between 30 and 90 minutes, and they will be scheduled based on the specific needs of the organization and the discretion of the surveyors. There are also several optional activities that surveyors may add if they deem them necessary.

The survey will end with some time to prepare a report of the survey findings and then an exit briefing with the CEO and an exit conference with the organization. From there, it’s just a matter of waiting for the official verdict on your accreditation and any quality improvements the surveyors found were needed. Then, in another 36 months, the whole process starts again.

What do I need to have for a Joint Commission survey?

A significant part of the survey will be spent going through paperwork to make sure you are meeting certain requirements around staffing, performance improvement, infection prevention, Environment of Care, emergency management, and standards compliance.

You can find the full list of required documentation, but here are some examples of what you’ll need to have ready:

• Hospital license
• CLIA certificates
• Organization chart
• Organ, tissue, and eye procurement policies
• Performance improvement data from the past 12 months
• Patient flow documentation
• Analysis from a high-risk process
• Environment of Care data
• Emergency management documentation
• Infection control surveillance data from the past 12 months
• Available regulatory reports (CMS, state)
• Medication management policy
• And more

You’ll also want to have a list of staff members who will assist in the survey. These staff members will guide the Joint Commission surveyors through the facility for the duration and provide any assistance needed.

Effective Joint Commission Survey Preparation

It might seem impossible to prepare for an unannounced survey from a regulatory agency, but it’s not. Even as one survey wraps up, your hospital should be preparing for the next. Joint Commission standards are published in the E-dition and updated regularly, so you can stay on top of them. And you can prepare your facility and staff for the actual survey event by following these steps.

1. Make sure all employees are aligned on goals

Since your survey involves all of your staff, make sure everyone knows exactly what they should be doing during the event. Your healthcare providers need to know all the standards relevant to their positions. Keep people up to date and focused on consistent quality care through regular safety moments or meetings and clear communication on a daily basis.

2. Establish communication plans for before, during, and after the survey

Clear communication during a joint commission survey will help you stay organized and moving efficiently through the process, and it will help your staff feel prepared to do their best. So, build your hospital’s communication plan in advance. Create notification templates for the event and test them, such as alerts to the internal survey team when TJC surveyors arrive. Run drills so your staff knows what the message will look like and how to respond. Rapid notifications can alert all staff of the event at once to maximize the brief preparation window.

Here are a few examples of Joint Commission survey notifications you can templatize:

3. Go through previous survey notes

Look at your survey performance from the past, and make sure you have maintained whatever required improvements you made. You’ll also want to double-check that standards haven’t changed since then.

4. Check documentation

Since record management is such a big part of your survey, start tracking down and organizing things as soon as possible. You don’t want to be scrambling for a lost file or trying to come up with reporting data at the last minute. You can create a documentation checklist to run through once a quarter or so to make sure everything is up to date and accurate.

5. Assign your survey team

You may not know who is going to be on site when the survey starts, but you can create different survey team shifts as you get closer to your general survey time frames. Pick staff members who are friendly, helpful, and know the organization so they can be the most supportive to the surveyors.

6. Conduct a mock survey

Doing a trial run is a great way to show your staff, new and tenured, what the survey is like. Three years can feel like a long time in fast-paced hospital environments, so employees may forget critical steps. Having a test run of the process will help things run much smoother on the actual day. This can be done either as a full-scale drill, or a tabletop exercise.

What Joint Commission Standards Mean for Your Safety Goals

Meeting Joint Commission standards and doing well during the survey are about more than just checking the box and getting accredited. These standards are built around keeping your facility a safe place for patients to receive care and treatment—and a safe place for staff to provide care and treatment in turn. When you think about preparing for your survey, think about how these improvements will directly impact your employees and patients. Establishing these improvements over time is the best way to support your overall safety goals, rather than cramming in unsustainable changes, last minute, before your next survey.