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What is the Joint Commission Survey for Healthcare Organizations? 

Sep. 19 2019 - Debra Andrews

Because of a misconception that The Joint Commission’s survey only focuses on healthcare and medicine, hospitals often miss the environment of care and life safety standards included in the survey. Here’s a helpful summary of the survey to ensure your facilities director is ready to help you pass all the standards—not just the most widely known. If you’d like more information, you can also download our free The Joint Commission Survey Summary Tip Sheet.

FREQUENTLY ASKED QUESTIONS ABOUT THE JOINT COMMISSION

  1. What is The Joint Commission? Founded in 1951, The Joint Commission is an independent, unbiased, non-profit organization assessing healthcare organizations to ensure quality, high levels of maintenance and safety, and standardization of care. The Joint Commission seeks to improve public health care.
  2. Do they collaborate with other organizations? The Joint Commission works with the American Society for Healthcare Engineering (ASHE) to create the standards.
  3. Who do they accredit? The Joint Commission accredits and certifies around 21,000 healthcare organizations and programs in the US.
  4. What is included? The Joint Commission has 28 hospital core measures, and the hospital accreditation standards number more than 250.
  5. Who recognizes them? Their accreditation is recognized nationwide.    
  6. What is earned by your accreditation? You earn their Gold Seal of Approval and this symbol of quality is recognized across the country.

WHAT TO EXPECT BEFORE AND AFTER THE JOINT COMMISSION SURVEY

  1. Pre-work: The Joint Commission requires hospitals to complete a periodic performance review (PPR) every year. This portion of the survey process gives them opportunities to prepare for the survey. Since one of the goals of The Joint Commission is to ensure high levels of maintenance and safety, a healthcare organization looking to prepare for this survey can enlist an expert in facility assessment and maintenance management to do recurring inspections and document their process of regularly inspecting and maintaining critical equipment.
  2. The Who, What, When: The surveyor team from The Joint Commission includes a combination of healthcare professionals along with a Life Safety Code & Environment of Care specialist, who is usually a Facilities Manager/Director and/or Safety Officer. The surprise visit will take place a minimum of once every 39 months (or 24 months for labs) and last for approximately one week.  
  3. What happens after it’s over? If a facility does not pass or passes with low marks, The Joint Commission will return to ensure they have corrected all the areas where they were not in compliance. The Joint Commission has the following levels of accreditation (from best to worst):
    1. Accreditation
    2. Accreditation with Follow-up Survey
    3. Limited Accreditation
    4. Preliminary Denial of Accreditation
    5. Denial of Accreditation

THE BENEFITS OF THE JOINT COMMISSION ACCREDITATION

  1. Insurance: Perhaps at the top of the list is this benefit. To be considered a Medicare provider, you must be accredited by The Joint Commission, or one of the other organizations approved by the Centers for Medicare and Medicaid (CMS). If a healthcare organization meets Medicare's standards, then other insurance companies will accept the healthcare organization as one of their preferred providers.
  2. General: Through the accreditation process, your organization will continuously be working on risk management and improving their performance.  
  3. Publicity: The final accreditation decision will be posted on Quality Check, a website where potential clients can shop for accredited organizations. Your hospital may publicize how it performed compared to other accredited hospitals.   
  4. Competitive: A hospital that is not accredited will quickly lose ground when compared to accredited organizations who can:
    1. Use the Gold Seal of Approval to promote their organization’s accreditation.
    2. Distribute the brochure “We Received the Gold Seal of Approval from The Joint Commission.”
    3. Direct patients, residents, or clients to the Quality Report, which includes the accreditation decision, a listing of accredited sites and services, special quality awards, level of compliance with the National Patient Safety Goals, and for hospitals, National Quality Improvement Goals.
    4. Send a press release or give a news conference.
    5. Notify any state or metropolitan provider association of which your organization is a member.
    6. Notify the benefit manager at insurance carriers whose clients use your services.

HOW FACILITIES DIRECTORS CAN PREPARE FOR THE JOINT COMMISSION

The Joint Commission identified the five most challenging hospital accreditation standards in the first half of 2013. Of the five standards that were most frequently deemed not compliant for hospitals in the first half of the year, 3 of them were tied into the facilities aspect of an organization. These standards point to the need for facility directors to be involved in the preparation leading up to this survey.

A facility director will be responsible for things like the utility systems, means of egress and egress requirements, healthy ADA and accessibility assessment, LS protection, and automatic suppression systems. Here are some other considerations that can help their preparation:

  1. The Joint Commission will look to see that the healthcare organization has identified its critical systems. Critical systems are those that, if they go down, will take the organization offline. The Joint Commission will be looking for maintenance records to ensure certain measurements and standards have been met.
  2. It will be beneficial to partner with a company who can help the facility director identify any shortcomings before their survey. These companies can provide the following:
    1. A full equipment inventory
    2. A Facility Condition Audit
    3. Help to set up a work order system
    4. Equipment Inventory Services and Preventative Maintenance (PM) Schedule Development Services to help with the Management Plans
    5. Services to ensure the organization meets the requirement to have Operation & Maintenance (O&M) manuals for all facilities equipment and PM schedules based on the manufacturers’ recommendations in the manuals

Health care organizations do not have to seek The Joint Commission accreditation. However, there are numerous benefits to accreditation, and facility directors need to be vigilant in preparing their organizations for a surprise visit by The Joint Commission. Start preparing even before applying for accreditation, so that you can reap the many benefits of passing the survey.

Joint Commission Survey Summary Tip Sheet

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