Evaluate your organization's readiness plan

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Take these steps after your Joint Commission survey

Editor’s note: The following is an excerpt from the new Joint Commission Survey Coordinator’s Handbook, Ninth Edition, by Patricia Pejakovich, RN, BSN, MPA, CPHQ, senior consultant with The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and Steven W. Bryant, vice president and managing director of The Greeley Company.

Treat the completion of your unannounced survey as a performance improvement outcome and assess the strengths and weaknesses of your continuous survey readiness process. You may choose to do so in two separate sessions: one to address the rollout plan, and the other to address standards compliance. This is not an exercise to discuss perceptions of surveyor accuracy, RFI clarifications, or how to submit evidence of standards compliance; it is a retrospective review of your organization’s methods of preparing for continuous standards compliance and readiness for an unannounced survey. Include the following people in your assessment of the rollout plan:

The survey coordinator

Designated staff members with assigned tasks

Include these people in your assessment of standards compliance:

Chapter team leaders

The survey coordinator

The following are the work steps for these sessions:

1. List the steps of the rollout plan that worked well and achieved the desired results.

2. List identified issues or concerns and determine what processes in the defined plan did not occur as anticipated. Seek input from attendees of alternative methods to prevent a reoccurrence.

3. Revise the rollout plan and test it in a subsequent drill.

4. Review the survey findings from the report left on-site by the surveyors.

5. Discuss which findings were anticipated or unanticipated based on your PPR, presurvey tracers, or data monitored by chapter teams.

6. Identify factors that may have affected results.

7. Brainstorm changes in chapter-team functioning that may positively affect standards compliance.

8. Implement the changes within chapter teams.

9. Evaluate the changes for effectiveness.

Tips for success

This may be your first unannounced survey, so don’t be too hard on yourselves if everything did not go exactly as planned. Incorporate lessons learned into your rollout plan and then move on.

Identify techniques from the more successful teams and apply them to those that are struggling. Don’t be afraid to reassess team composition and make changes as needed.

Learn to manage your EP evidence documents, such as meeting minutes and reports, in a way that keeps them survey-ready. Action items at this month’s meeting should become unfinished business in the next agenda to ensure completion.

Generate additional interest in chapter teams by showcasing innovative ideas for patient care improvements. Publish such work in your hospital newsletter, but also consider submitting an article to a professional newsletter or listserv.

What to do if you add new services

Before adding new services, meet with various chapter team leaders to determine what processes may be applicable. Creating policies, procedures, and forms that comply with Joint Commission standards, CMS regulations, and state regulations is far easier than revising at a later date. At all times, include patient safety in your development. Some additional tips include:

When conducting your PPR, do so as a true self-assessment and focus on each EP. Note the evidence that allows you to score the EP compliant.

Identify the need for compliance and track interventions to bring the EP into compliance.

Read Joint Commission publications monthly and determine whether any organizational changes are necessary to maintain compliance.

Ensure that Joint Commission messages are being received on the extranet; spam blockers occasionally intercept Internet communications, and you may miss out on timely information.

Note: For more information about the Joint Commission Survey Coordinator’s Handbook, Ninth Edition, or to order a copy, go to