Is Your Healthcare Facility Joint Commission Survey Ready?

While Joint Commission accreditation lends credibility to a healthcare organization and helps them earn public trust, it also comes with a caveat: regular visits or “surveys” from Joint Commission officials. Since the Joint Commission has no duty to inform the facility of a visit ahead of time, healthcare facilities looking to maintain their accreditation must always be ready. In this post, I’ll share my perspectives on survey readiness and a few best practices from my work with hospitals and compounding pharmacies. 

What is the Joint Commission? 

The Joint Commission is a nonprofit organization that accredits and certifies healthcare organizations in the United States, providing evidence that they meet established patient care and safety standards. While hospitals are the primary focus, Joint Commission accreditation and certification is also available to surgery centers, mental health, long-term care, hospice care, urgent care, rehabilitation centers, and other types of healthcare facilities.  

Joint Commission accreditation is required by the Centers for Medicaid and Medicare (CMS) and can influence reimbursement from private insurers as well. For healthcare facilities that don’t accept Medicaid or Medicare, Joint Commission accreditation is voluntary but publicly validates that the facility meets certain standards and can help them gain credibility in the broader healthcare community. 

Three Critical Elements of Joint Commission Survey Readiness 

A Joint Commission survey evaluates numerous aspects of the healthcare facility’s operations, including patient safety protocols, infection control measures, documentation accuracy, medication management, and staff competence. Preparing for a Joint Commission survey is crucial because the process is comprehensive and exacting. It can also be nerve-wracking as the consequences of failing an audit can be high, professionally and financially. 

There are many online survey-readiness checklists that may be useful for ensuring your bases are covered. At the same time, it’s important to take a bird’s-eye view of survey readiness to avoid getting lost in the details. The way I see it, survey readiness boils down to three main responsibilities: 

#1 Following the standards. There are numerous standards designed to protect patient safety and promote effective outcomes. Some may be required, while others are industry best practices. Whether required or voluntary, the more closely you follow the standards that apply to your type of healthcare facility, the more survey-ready you will be. 

All facilities, whether Joint Commission accredited or not, should assign a point person with the primary responsibility for knowing which standards apply and ensuring adherence to the standards. For many healthcare organizations, this is the compliance manager. For larger organizations, such as hospitals with multiple departments, locations, or services, compliance is more likely to be handled by a team with each member assigned specific responsibilities. 

#2 Fill the gaps. Many of these standards are “standards of minimums”, meaning they establish baseline requirements but leave many specifics up to the facility. Most of my work is with USP <797> clients, so I often use it as an example. This standard minimum protocols for ensuring the safety and the efficacy of compounded sterile pharmaceuticals (CSPs), while at the same time making it clear that the facility needs to conduct its own risk assessment to ensure the standard is fully met.  

In addition to USP <797> sampling and analysis, Pace® provides many other testing and analysis services to help clients adhere to patient safety standards and fill the gaps in their infection control management practices. Some of the most popular services include: 

AAMI ST 108 Testing Services for Reusable Medical Devices 

Legionella Testing 

Waterborne Pathogens 

Water Management Planning 

Mold and Fungal Testing 

Asbestos 

Microbial Indoor Air Testing 

Cleanroom Certification 

Instrument Maintenance, Repair, and Calibration 

#3 Document everything. While documentation requirements are outlined in many industry standards, this isn’t always given the attention it deserves. I cannot tell you how many times I’ve gotten calls from panicked clients telling me the Joint Commission just showed up. Typically, the client calls me because the Joint Commission surveyors want to see some piece of documentation that the client can’t find, such as sampling results covering a specific timeframe. Keep in mind though that surveyors can ask for just about anything. Not too long ago, one of my clients was asked for a copy of the certificate of analysis (COA) for a media shipment received several months ago. (This call is one of the reasons I recently wrote a blog post about best practices for managing COAs.)  

True Survey Readiness Requires Addressing the Weakest Link 

Survey readiness requires focused attention in a lot of areas. From my experience, documentation management can be the weakest link in Joint Commission survey readiness. The pharmacies I work with want to ensure patient safety, so they follow the standards to the letter. They are also pretty good at filling in the gaps through risk assessments and custom SOPs. Unfortunately, human nature takes over when it comes to documentation. Like many of us, filling out and filing paperwork isn’t their favorite thing to do!  

I cannot emphasize the importance of documentation enough. Nothing is more frustrating than knowing you followed a particular standard or SOP but being unable to prove it because you can’t find the documentation. Working with a laboratory partner with a good online portal is helpful. However, there is so much more to ensuring patient safety than what we’re involved in. Developing your own documentation SOPs and ensuring they are followed is really the only way to ensure your organization is truly survey ready. 

Are You Survey-Ready? 

Joint Commission surveys may be stressful, but they don’t necessarily need to be. Just complying with the standards is not enough. Healthcare facilities need to be able to prove compliance through documentation. Making survey readiness a top priority can take much of the stress out of the accreditation process. If you have questions on this or other healthcare environmental compliance topics, reach out to us. We’d love to hear from you! 

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