How to Survive a Joint Commission Survey
A Joint Commission survey may feel like something you should prepare for, but Craig Garner, of Garner Health Law Corp., has some advice that seems a little contrary: “Do absolutely nothing.”
Ideally, your facility is already doing everything it’s supposed to be doing every single day, Garner says. “When I was running a hospital, I never hesitated to let employees speak to surveyors. They know their jobs better than the regulators do. It’s only a question of whether they’re doing them properly.”
The Joint Commission on-site survey process is data-driven, patient-centered and focused on evaluating actual care processes, says The Joint Commission’s Katie Looze Bronk. The objectives include evaluating hospitals and providing education and “good practice” guidance to help staff improve performance. The surveys are designed to be organization-specific and consistent and to support the organization’s efforts to improve performance.
What to Expect from a Joint Commission Survey
Hospitals can expect an unannounced survey between 18 and 36 months after their previous full survey, Bronk says. Most hospitals receive no notice of the survey date. An unannounced survey also may be conducted in response to a report of a patient safety or quality concern.
“In my opinion, actually knowing the day they’re coming can be more stressful,” Garner says. In some ways, you’ll be caught off guard no matter what. “Key people may not be there, but they understand that; the hospital still runs 24/7.”
The Joint Commission encourages hospitals to prepare a plan for staff to follow when surveyors arrive, Bronk says. “The plan should include greeting surveyors and notifying leaders and staff upon their arrival, as well as identifying a location for surveyors to work, validating the survey and identifying who will escort the surveyors.”
Smaller hospitals may host three or four surveyors, while larger hospitals will see more, Garner says. Different surveyors focus on administration, clinical performance and other departments within the hospital.
Aim for Year-Round Excellence
It’s important to remember that the accreditation process goes beyond the on-site survey, Bronk says. For example, Joint Commission-accredited healthcare organizations undergo an annual Intracycle Monitoring process, which is an annual accreditation requirement in which an organization meets with a Joint Commission standards expert to review its compliance with applicable standards.
“Working with your hospital staff from top management down throughout the year is so important,” Garner says. He compares it to taking a class: The best way to pass isn’t to cram for the final the night before but to diligently read the texts and keep up with the materials throughout the course.
“You can’t memorize certain things before the survey, such as code colors, because they’re not quizzing you about those things. They just want to know how you do your job and make sure it’s the best you can do.”
The Joint Commission has a Survey Activity Guide available, which contains information to help organizations prepare for the on-site survey, including an abstract of each survey activity that includes logistical needs, session objectives, an overview of the session and suggested participants, Bronk says.