The Joint Commission Survey Process



For over 50 years the Joint Commission (JC) has been accrediting hospitals. For those acute care hospitals receiving its accreditation, it is akin to receiving the Good Housekeeping Seal of Approval - but in health care. The approval indicates that a hospital has met the JC's high performance standards, as well as helps hospitals improve their performance, raise the level of patient care, and demonstrate accountability in the rapidly changing health care marketplace (Joint Commission, 2008).

In 2004, the survey process was modified to focus on data and the patient. For most surveys, the surveyors arrive unannounced. The first hour of the day is utilized for planning the survey activities, which includes an opening conference, leadership interview, validation of the organization's implementation, and monitoring of the Plan of Action for the Periodic Performance Review (PPR), which is a mid-cycle assessment of the organization's standards compliance and required annually (the facility does a self-evaluation of compliance with applicable standards and develops a Plan of Action for areas of non-compliance. The organization must obtain the JC's approval for this plan), and a review of specific documents provided by the facility. If documents are not available, they will immediately begin to evaluate patient care and service to a specific patient through what is called a tracer. This means they select a patient, and use that patient's medical record as a roadmap to move through the organization to assess and evaluate the organization's compliance with JC standards and the organization's own systems of providing care and services. They essentially retrace what the patient has experienced and talk to staff involved in that patient's care. The surveyors are looking for trends that point to compliance issues in the organization's systems. They provide education to the staff and leaders, and share best practices. They also will speak to patients, with their permission.

The average survey consists of a team of three surveyors and lasts an average of three days. The approximately eleven tracers are garnered from a current inpatient list, and the surveyors usually select those patients who have received a multitude of services throughout their stay.

When the survey is over, they will typically meet with the facility's administration (Exit Conference) and if problems have been identified, the facility has 45 days from the end of the survey to submit Evidence of Standards Compliance and identify Measures of Success, which is used to assess sustained compliance over time. Four months after the facility receives approval for the Evidence of Standards Compliance, they must submit data on its Measures of Success demonstrating a track record.

The accreditation decision is based on the number of standards that are scored not compliant, and compliance is scored by determining compliance with the Elements of Performance - performance expectations that must be in place for a facility to provide safe, high quality care, treatment and services (Joint Commission, 2008). The scores are not forthcoming until the JC receives and approves the facility's Evidence of Standards Compliance submission. As of January 1, 2008, the decision categories are accreditation, provisional accreditation, conditional accreditation, preliminary denial of accreditation, denial of accreditation, and preliminary accreditation.




The Joint Commission. (2008).


Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


Articles in this issue:


  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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