
Hospitals are held to high standards regarding quality-of-care guidelines and regulations. To ensure these processes are working according to plan and patient safety remains a priority, hospitals and other facilities are accredited by The Joint Commission. This regulatory nonprofit sets standards and evaluates healthcare organizations in the United States. The accreditation process involves an on-site visit from The Joint Commission every three years, which is understandably an intimidating time for hospitals. However, there are several ways hospitals can prepare for this survey, including taking advantage of the many complimentary resources provided by The Joint Commission, such as webinars and training materials, and building a survey-specific communication plan.
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What You'll Learn

Plan ahead, even though the survey is unannounced
Although The Joint Commission's accreditation survey is unannounced, hospitals can still plan ahead and prepare for the visit. The survey, which occurs every three years, assesses the quality of care provided by the facility and whether it meets accreditation standards.
To prepare, hospitals should take advantage of the complimentary resources provided by The Joint Commission, such as a JC Account Executive to answer questions, a Snapshot of Survey Day, a Readiness Roadmap Toolkit, webinars, and training materials. Hospitals should also maintain a strong culture of safety underlying all processes and patient care to ensure they are always prepared to meet the highest standards.
In addition, hospitals can develop a survey-specific communication plan in advance, including notification templates such as "TJC surveyors are here!" and run drills to ensure staff recognize these messages and know how to respond. It is also important to keep up with any required improvements from past surveys and to double-check for any changes in standards to ensure current compliance. Hospitals should also have a list of staff members who will assist during the survey, guiding the surveyors and providing any necessary assistance.
By planning ahead and utilizing the resources provided by The Joint Commission, hospitals can ensure they are well-prepared for the accreditation survey, even if it is unannounced.
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Prepare staff with briefings and clear communication protocols
Preparing for a hospital survey is crucial, and while the actual survey date is usually unknown, you can take several steps to get your staff ready. Firstly, it is essential to cultivate a strong culture of safety and excellence in your hospital. This means that staff should always be prepared to meet the highest standards, and providing excellent patient care should be a way of life, not just something done in anticipation of a survey.
However, when a survey is imminent, there are several steps you can take to ensure your staff are fully briefed and ready. Firstly, take advantage of the resources provided by the Joint Commission, such as webinars, training materials, and toolkits. These resources can help you understand what to expect and how to prepare. Additionally, you can create a survey-specific communication plan that includes notification templates to alert staff when surveyors arrive. Running drills will help staff recognize these messages and know how to respond promptly.
It is also essential to have a list of staff members who will assist during the survey. These individuals will guide the surveyors and provide any necessary assistance. Ensure that these staff members are well-briefed on safety procedures and general orientation to guide surveyors confidently. You can also provide staff with an hour-by-hour outline of the survey, so they know what to expect and can prepare accordingly.
Finally, remember to study your past survey performance and ensure that any required improvements have been made. Double-check for any changes in standards to ensure current compliance. By following these steps, you can ensure that your staff are well-prepared, briefed, and ready to assist during a hospital survey.
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Ensure all documentation is in order
Hospitals are held to high standards regarding quality-of-care guidelines and regulations. To ensure that processes work according to plan and that patient safety is a priority, hospitals are accredited by The Joint Commission, a regulatory non-profit that sets standards and evaluates healthcare organisations in the United States. The process, known as a survey, happens every three years and is unannounced.
To prepare for a hospital survey, it is important to ensure that all documentation is in order. Here are some tips to ensure that your hospital's documentation is in order and readily available for inspection:
- Maintain a strong culture of safety: Embed a strong culture of safety in all your processes and patient care. This will help you meet the highest standards and ensure that you are always prepared for a survey.
- Build a survey-specific communication plan: Create a communication plan in advance to notify staff of the survey and what is expected of them. This could include customisable, multichannel messages and notification templates. Run drills so that staff can immediately recognise these messages and know how to respond.
- Study past survey performance: Review your hospital's performance in past surveys and ensure that any required improvements have been implemented. Check for any changes in standards since the last survey to ensure current compliance.
- Keep records updated and easily accessible: A large part of the survey will involve record management. Maintain a documentation checklist and review it periodically to ensure that all records are up to date and easily accessible when the surveyors arrive.
- Utilise available resources: The Joint Commission provides a wealth of complimentary resources to help hospitals prepare for surveys, including a JC Account Executive to answer questions, a Snapshot of Survey Day, a Readiness Roadmap Toolkit, webinars, and training materials. Take advantage of these resources to prepare for the survey effectively.
By following these steps, you can ensure that your hospital's documentation is in order and readily available for inspection during a survey.
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Assign staff to guide surveyors
When preparing for a hospital survey, it is important to assign staff members to guide the surveyors. This ensures that the surveyors can navigate the facility efficiently and have access to all the necessary information. Here are some tips to consider when assigning staff to guide surveyors:
Firstly, it is advisable to create a list of staff members who will be assisting with the survey. These individuals should be knowledgeable about the hospital's processes and patient care standards. They should also be familiar with the survey process and the specific requirements of the surveying body. For example, if your hospital is preparing for a Joint Commission survey, utilise the complimentary resources provided, such as a JC Account Executive who can answer any questions that arise.
Secondly, consider the number of staff needed. Depending on the size and complexity of your hospital, you may require multiple staff members to guide the surveyors. Ensure that there are enough staff members available to provide efficient guidance and assistance to the surveyors throughout their on-site visit.
Thirdly, designate specific roles and responsibilities for each assigned staff member. For instance, some staff may be responsible for escorting the surveyors and providing logistical support, while others may be tasked with gathering and presenting relevant documentation. Clear role assignments ensure a smooth survey process and efficient utilisation of resources.
Additionally, it is beneficial to conduct staff training or briefings prior to the survey. During these sessions, staff members can become familiar with the survey process, the expectations of the surveying body, and any specific guidelines or standards that are being assessed. This preparation will enable them to confidently guide and support the surveyors.
Finally, encourage open communication between the assigned staff members and the surveyors. Emphasise the importance of clear and timely communication to address any questions or concerns that may arise during the survey process. Efficient communication ensures that any issues are promptly addressed, fostering a positive and collaborative environment during the survey.
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Use the complimentary resources provided by the Joint Commission
The Joint Commission provides a variety of complimentary resources to help hospitals prepare for their survey. Firstly, they assign a JC Account Executive to answer any questions and provide support. Additionally, they offer a Snapshot of Survey Day, which gives an overview of what to expect during the on-site visit. This includes a sample survey agenda, outlining the survey hour-by-hour, and a description of the on-site survey events. This resource can help hospitals understand the survey process and prepare accordingly.
The Joint Commission also offers a Readiness Roadmap Toolkit, providing tools and guidance to ensure hospitals are ready for the survey. Furthermore, they provide hundreds of webinars and training materials, covering various topics related to the survey and hospital accreditation. These webinars and training materials are valuable opportunities for hospitals to learn and ensure they meet the required standards.
To access additional resources, hospitals can log in to the Joint Commission Connect® extranet site. This site offers a wealth of information, including reports summarizing the rationale and references for new Joint Commission requirements. It also provides data analytics tools, such as the SAFER® Dashboard, which allow hospitals to view and track their survey findings, compare their performance to other organizations, and identify areas for improvement.
The Joint Commission's complimentary resources are designed to assist hospitals in improving the safety and quality of care they provide. By utilizing these resources, hospitals can gain valuable insights, stay informed about the latest standards and requirements, and ensure they are well-prepared for their accreditation survey. These resources demonstrate the Joint Commission's commitment to working alongside hospitals to raise the bar of healthcare excellence.
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