Preparing for a Joint Commission Survey: Overview and FAQ

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Written by Ayana Dunn, BSN, RN Content Writer, IntelyCare
Nurses and physicians take a look at the results of a CMS Joint Commission Survey.

Do you feel tense at the mere thought of a Joint Commission survey at your facility or residence? You’re far from alone. This in-depth evaluation process can certainly feel daunting, even if you’re fully prepared.

The good news is that there are actionable steps you can take to set your facility up for success, no matter when the surveyor decides to show up. Below, we explore The Joint Commission’s purpose and what to expect from a survey, while answering commonly asked questions to help you stay ahead of the game.

What Is the Joint Commission and Why Is it Important?

The Joint Commission on Accreditation of Healthcare Organizations, often called The Joint Commission or JCAHO, is an organization that strives to uphold safety and integrity in healthcare through accreditation. They evaluate healthcare facilities based on quality standards and educate facilities on ways to improve care. JCAHO accreditation impacts public health by promoting safe practices within its facilities.

Approximately every three years, JCAHO representatives visit healthcare facilities — without advance notice — to get an honest idea of how they function. Some of the factors surveyors evaluate include accurate documentation, safe patient care, and building-wide safety measures.

Although accreditation is not a requirement for a facility to operate, it holds participating healthcare facilities accountable. If they don’t pass the survey, they risk losing Medicare reimbursements. In addition, choosing to pursue JCAHO accreditation shows prospective patients that your facility values ethics and transparency.

What Are the Standards for a Joint Commission Survey?

What does The Joint Commission look for? Although all of JCAHO’s standards are ultimately rooted in patient safety, they can vary based on the type of facility being evaluated. It’s important to refer to The Joint Commission standards specific to your facility to be prepared for an evaluation.

For example, the criteria for an inpatient medical hospital will be different from those of a skilled nursing facility due to the differences in the needs of patients. Below are some examples of patient safety standards that JCAHO evaluates while surveying an assisted living facility:

  • Use at least two ways to correctly identify residents.
  • Minimize falls by identifying residents most likely to fall and taking preventative actions.
  • Prevent spread of infection by utilizing proper hand hygiene.

Overall, JCAHO evaluates ways in which facilities pose a risk to their patients. They’ll check for medical errors, safety concerns, staff competence, and your adherence to guidelines set by regulatory bodies in healthcare. They also check for potential risks to visitors in the building. Some examples of risks include:

  • The extent to which the facility follows guidelines set by the FDA, CDC, and other regulatory measures
  • Potential infection due to nurses with long fingernails
  • Expired medications
  • Exposed wires and broken outlets

What Are the Most Common Joint Commission Violations?

While specific violations depend on the facility, there are some overarching patterns throughout the industry. Understanding common pitfalls can help your facility be better prepared for the next survey. Here are a few examples of common violations:

  • Insufficient protection from the potential hazards of fire and smoke
  • Risk of infection associated with medical equipment and supplies
  • Ineffective waste management

What to Expect on the Day of a Joint Commission Survey: FAQs

Knowing what will happen when JCAHO visits can help ease some of the stress on your team. Thankfully, these visits tend to have a pattern. Keep reading to learn more about this process.

Who Are JCAHO’s Surveyors?

Joint Commission surveyors include a variety of healthcare professionals who offer their unique perspectives. They can include nurses, physicians, facility administrators, and more. You won’t know who exactly will be visiting your facility until you meet them.

How Long Does a Joint Commission Survey Last?

The length of a survey varies based on the findings, the size of your organization, and what is happening in your facility on that particular day. Plus, site visits include the time it takes for the surveyors to meet with your team. Expect them to be there for at least one day, with the potential for multiple days.

What Happens on the Day of the Survey?

Once the surveyor checks in and identifies themself in the reception area, you will verify their credentials. Then, you and other members of management will meet the surveyors and organize how they’ll conduct the survey. Your team will have about an hour to gather necessary materials and inform staff.

Then, the surveyor will tour the building to ensure it meets environmental standards. They will also assess your facility’s patient care and documentation. To do this, the surveyor will randomly choose a patient to investigate, look through their medical records, interview staff involved in their care, and potentially speak with the patient directly.

At the end of the process, the surveyors will share their findings with your team. They may provide requirements for improvement (RFI), for which you have 60 days to prove your facility made the necessary changes.

If your facility is successful in addressing the RFIs, you will be accredited. If not, you will lose accreditation until you can pass the survey the next time JCAHO representatives return. If you don’t receive any RFIs, your accreditation approval becomes active on the last day of your survey.

Preparing for a Joint Commission Survey: FAQs

Even though the timing of these surveys is a surprise, you can take steps now to improve your facility’s readiness for when survey day comes. It’s simple: practice what you preach. Strive to maintain quality standards at all times instead of scrambling when the surveyors show up. Below are some answers to common questions to help you have a successful JCAHO survey.

How Often Are Joint Commission Surveys?

On-site surveys typically occur every 18–36 months. That should leave plenty of time for you to take steps toward fulfilling your goals. Having a general idea of when a survey will occur helps give you a sense of how to pace the changes you want to implement.

How Can You Prepare Management for a Joint Commission Survey?

You and your fellow administrators are responsible for implementing JCAHO’s standards, so it’s important for you to lead by example. Below are some tips on how to do this:

  • Make sure the licensure and credentials of your staff remain up to date.
  • Meet regularly to address any concerns amongst your management team.
  • Perform periodic self-assessments based on the JCAHO survey guide.
  • Host mandatory workshops or education modules to train staff on safe practices.
  • Read newsletters to stay up to date on industry trends that could impact JCAHO standards.

How Can You Prepare the Building and Equipment?

A key part of the survey process is the building inspection. Here are some examples of how you can ensure your environment is up to par:

  • Ensure you’re following FDA medical device protocols.
  • Delegate the task of discarding expired medications.
  • Be diligent about decreasing loose wires, idle equipment in the hallway, and other safety hazards.

What Happens After the Survey Is Complete?

When the survey is finished, take a moment to decompress and process any feedback they shared. After that, get ready for the most important part: the official results.

If you received any RFIs, take this as a learning opportunity rather than a slap on the wrist. JCAHO’s results reveal what you should keep doing and how to grow. You can expect to wait two weeks to two months for the official results.

Are Joint Commission Results Public?

A list of JCAHO accredited institutions is available to the public. Finding this information is quick and free of cost. An easily accessible list of these results upholds transparency in healthcare.

What Are the Benefits of JCAHO Accreditation?

When you’ve been accredited by JCAHO, you and your coworkers can take pride in your exemplary work. Meeting this gold standard can boost employee morale throughout your organization. You can be assured that your facility is leading by example, and patients can feel safe knowing they’re receiving top-notch care. Accreditation can also boost your reputation, leading to more people seeking your services.

Is Your Facility Ready for Its Next Joint Commission Survey?

If you and your staff are dedicated to upholding JCAHO standards on a daily basis, you’re well on your way to attaining accreditation. Stay ahead of JCAHO standards and more industry insights by reading IntelyCare’s newsletter.