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The Survey Process

How the Joint Commission Surveys for Quality

The Joint Commission surveys hospitals every three years. Surveys are scheduled approximately six weeks in advance, although hospital staff may spend months preparing for the visit. When the survey date arrives, a team of experienced health professionals—usually at least one doctor, one nurse and a hospital administrator—travel to the hospital.

Over several days, they conduct a top-to-bottom review of the hospital, evaluating compliance with standards through observation, document review, and interviews with patients and staff. Some of the areas evaluated, and examples of things the team looks for, include:

Patient rights

  • Are patients able to accept or refuse certain treatments?
  • Is patient confidentiality maintained?

Patient assessments

  • How are patient needs determined through physical examinations, health histories and appropriate diagnostic tests?

Medication use

  • How does the hospital prepare, dispense and administer medications? 

  • Are systems in place to minimize medication errors?

Patient and family education and responsibilities

  • Does the hospital properly address physical, mental, cultural or language barriers that patients may have? 
  • Does the hospital help patients understand how to take their medications and use medical equipment?

Environment of care

  • Does the hospital comply with fire and safety codes? 
  • Is medical equipment properly maintained?

Infection control

  • Does the hospital take steps to prevent and control infections? 
  • Are sterilization procedures carried out appropriately?

Credentialing

  • How does the hospital make sure that only qualified people are on the medical staff?

A Serious Process

Hospitals pursue accreditation, which is voluntary, to improve quality and patient safety. Accreditation fulfills licensure requirements in many states and may also substitute for Medicare and Medicaid certification. Insurers and other third parties are increasingly requiring accreditation as a prerequisite for eligibility.

No matter why a hospital seeks accreditation, the process is taken seriously. Hospitals pay the cost of their own evaluations, and results are automatically made available to the public. Doing well in a survey helps the hospital build public trust and attract medical staff.