Ambulatory Care Accreditation Survey Activity Guide January 2021 - The Joint Commission
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Ambulatory Care Accreditation Survey Activity Guide January 2021
Survey Activity Guide for
Ambulatory Care Organizations
January 2021What’s New?
New or revised content is identified by underlined text.
Changes effective January 1, 2021
• Surveyor Planning Initial – This activity has been eliminated for all programs. NOTE:
Surveyors will need as many documents as possible from the program-specific Document
Lists available for the Surveyor Arrival and Preliminary Planning activity.
• Special Issue Resolution and Surveyor Planning/Team Meeting – Special Issue
Resolution takes place throughout the survey; that is, surveyors do not typically wait to
address issues until a scheduled time on the agenda. Therefore, these activities will now
occupy the same 30-minute timeframe on the survey agenda and either one or the other
activity will be conducted by the surveyor based on need. Surveyors will inform the
organization which activity will take place.
• Survey Activity List – Updated to clarify applicability of the Life Safety Code® Building
Assessment activity.
• Life Safety Code® Building Assessment – Specified the NFPA editions that are being
surveyed.
• Behavioral Health Care and Human Services Accreditation Program Document List
and Survey Activity List – Updated to reflect the change in the accreditation program
name.
• Laboratory Accreditation Program Document List – List reorganized and one new item
included
• Sample Survey Agendas – Updated to reflect elimination of Surveyor Planning Session,
combining of Special Issue Resolution and Surveyor Planning/Team Meeting activities into
same time slot, and Ambulatory Surgery Center, sample two-day agenda reflects changes in
the Life Safety Surveyor schedule of activities.
• Ambulatory Surgery Center Life Safety & Environment of Care Document List and
Review Tool – Tool has been expanded to include additional environment of care related
documents for review.
• Imaging Document Review Guide – Introducing a new tool to help organizations compile
imaging services documents and data needed for surveyor review, based on the imaging
modalities provided by the organization.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021Ambulatory Health Care and Office-Based Surgery Organizations
Survey Activity Guide (SAG)
Table of Contents
Page
Number
How to Use this Guide 4
Prior to the Survey
Preparing for Surveyor Arrival 6-7
Survey Readiness Guide 8
Survey Document List 9-11
Survey Activities 12-13
During the survey
Surveyor Arrival and Preliminary Planning Session 15-16
Opening Conference 17
Orientation to Your Organization 18-20
Individual Tracer Activity 12-23
Special Issue Resolution 24
Surveyor Planning/Team Meeting 25
Daily Briefing (applicable if survey is two or more days) 26
Competence Assessment and Credentialing & Privileging 27-28
Environment of Care and Emergency Management Session 29-32
Life Safety Code® Building Assessment 33-34
System Tracer-Data Management 35
Clinical Leadership and Staff Discussion – Bureau of Primary Health Care only 36-37
Governance Discussion Session – Bureau of Primary Health Care only 38
Leadership Session 39
Surveyor Report Preparation 40
CEO Exit Briefing (Optional) 41
Organization Exit Conference 42
Following the Survey
What Happens After Your Joint Commission Survey 44-45
Appendix
Table of Contents 47
Behavioral Health Care and Human Services Accreditation Program Document List 48
Behavioral Health Care and Human Services Accreditation Survey Activity List 49-50
Laboratory Accreditation Program Document List 51
Laboratory Accreditation Survey Activity List 53
Tips for Conducting Mock Tracers 54
Program Specific Tracer – Continuity of Care 55
System Tracer – Infection Control 56
System Tracer – Medication Management 57
Sample Survey Agendas 58-64
Ambulatory Surgery Center Life Safety and Environment of Care Document List and 65-77
Review Tool
Imaging Document Review Guide 78-80
Key: The following abbreviations are used throughout this Guide to identify specific accreditation programs and the survey activities
applicable to the program.
• AHC – Ambulatory Health Care (surveyed from the Comprehensive Accreditation Manual for Ambulatory Health Care and not
the Hospital Accreditation Manual)
• OBS – Office-Based Surgery (surveyed from the Comprehensive Accreditation Manual for Office-Based Surgery and not the
Ambulatory Care Accreditation Manual)
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021How to Use this Guide
The Joint Commission’s Survey Activity Guide for ambulatory care and office-based surgery organizations
is available on your organization’s Joint Commission Connect extranet site.
This guide contains:
• Information to help you prepare for survey
• A description of each survey activity that includes session objectives, an overview of the session,
logistical issues, and suggested participants
• Sessions are listed in the general order that they are conducted.
A template agenda with a list of onsite survey activities are posted to your organization’s Joint
Commission Connect extranet site once the application is reviewed and processed by your account
executive. When the agenda and activity list are available, please review the material and think about the
people you might involve in the survey. The activity list includes a column in which you can record
participant names or positions next to each of the sessions. Identifying key participants (and their phone
numbers) for each session, including back-ups, is important. Consider including possible meeting
locations and surveyor work space in your planning documents. Review the sessions in this Survey
Activity Guide to learn about what will occur during the activity.
The template agenda and activity list include suggested duration and scheduling guidelines for each of
the sessions. On the first day of survey, there will be an opportunity for you to work with the surveyor(s)
to prepare an agenda for the visit that will fit with your day-to-day operations.
Please Note: Not all of the activities described in this guide are contained in the activity list or on the
agenda template. Many of the activities will take place during individual tracer activity. Surveyors will
incorporate these into the onsite survey when they are applicable to your organization.
Complex organizations (surveyed under more than one accreditation manual or that have more than
one service under one accreditation manual), will receive an activity list and agenda template for each of
the programs being surveyed (e.g., behavioral, home care, laboratory).
For multiple services surveyed under a single accreditation program, be sure to include contact names
and phone numbers from all of your organization’s services. For example, Ambulatory Care might have
the following services: Ambulatory Surgery Centers, Diagnostic Imaging Services, Diagnostic Sleep
Centers, or Urgent Care.
Also identify names or positions and phone numbers of activity participants from all of the programs on
these activity lists. Identify when it would be most effective to conduct an activity with all programs
present (e.g., Leadership, Daily Briefing, and System Tracer--Data Management) and suggest this to the
surveyors when they arrive.
This Survey Activity Guide is created for small and large organizations. Some organizations will have one
surveyor while others will have multiple surveyors. For Ambulatory Surgical Centers using The Joint
Commission for deeming purposes, this will include a clinician(s) and Life Safety Code surveyor.
If you have any questions about the number of surveyors who will arrive at your site, please contact your
Account Executive. If you are unsure of your Account Executive’s name or phone number, call the Joint
Commission at 630-792-3007 for assistance.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 4PRIOR TO THE SURVEY Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 5
Applicable Programs
AHC and OBS
Preparing for Surveyor Arrival
Overview
The surveyor(s) arrive unannounced or with short notice for most surveys. Exceptions to the
unannounced survey process include:
• Initial accreditation surveys that are not a Deemed Status survey (30-day advance notice)
• Early Survey Option – 1st and 2nd surveys that are not a Deemed Status survey (30-day advance
notice)
• Intra-cycle Monitoring (ICM) Option 2 and Option 3 surveys
Exceptions to the unannounced survey process may change at any time. Changes are published in the
Joint Commission newsletter Perspectives.
A seven-business day advance notice is given for the following Ambulatory Care Accreditation
Program re-survey types:
• Very small Ambulatory as defined in the Accreditation Process section of the accreditation
manuals (short notice)
• Department of Defense facilities
• Bureau of Prisons facilities and contracted prison facilities
• Immigration facilities
• Office-Based Surgery practices
• Telehealth Services
• Sleep Centers
• Ambulatory surgery centers that are not using accreditation for deemed status purposes
• Surgery/anesthesia services
• Medical/dental services
• Specified diagnostic/therapeutic services
• Mobile diagnostic services
Please Note: Organizations offering procedures/services from more than one of the above service types
(i.e. surgery/anesthesia + medical/dental + telehealth) are not eligible for a short notice survey.
Planning in advance for the surveyor’s arrival helps staff be better prepared for the survey. Whether the
surveyor arrival is announced or unannounced, the first hour of the surveyor’s day is devoted to planning
for your survey activities. This planning requires review of specific documents that can be found on the
Survey Document Lists for each accreditation program in the pages that follow. If these documents are
not available when the surveyors arrive, they immediately begin to evaluate the care, treatment, or
services provided to one of your patients served through an individual tracer.
Preparing for Survey
Prepare a plan for staff to follow when surveyor(s) arrive. The plan should include:
• Greeting surveyor(s): Identify the staff usually at the main entrance of your organization. Tell
them about The Joint Commission and what to do when the surveyor(s) arrive. Explain the
importance of verifying any surveyor’s identity by checking his or her Joint Commission picture
identification badge. Also log into your Joint Commission Connect extranet site to validate the
surveyor’s identity when possible.
• Who to notify: Identify leaders and staff to notify when surveyors arrive, including the individual
who will be the surveyor’s “contact person” during the survey. Identify alternate individuals in the
event that leaders and staff are unavailable. Create a list of their names and telephone numbers.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 6• A location for surveyor(s): Ask surveyors to wait in the lobby until an organization contact person
is available. Surveyor(s) will need a location that they will call their “base” throughout the survey.
This location should have an electrical outlet, phone access, and internet access.
• Validation of survey: Identify who will be responsible for the validation of the survey and the
identity of surveyors. Identify the steps to be taken for this process. (See Surveyor Arrival
Session for these steps.)
• The Survey Readiness Guide is a tool that helps you plan the survey (See page 8).
• Document Lists: Your organization should be prepared to have documents available for the
surveyor(s) as soon as your organization validates their identity. If this information is not
immediately available for surveyors at the Surveyor Preliminary Planning Session, they will begin
the survey with an individual tracer.
• Staff: Identify staff who will accompany the surveyors during the survey.
• Expectations for the survey: Identify your organization’s expectations for the on-site survey and
who will share these with the surveyor(s)
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 7Survey Readiness Guide
Actions to take when the
Responsible Staff Comments:
surveyor(s) arrives
Greet surveyor(s)
Check the Joint Commission Be sure to designate someone to access
Connect extranet site for your organization’s Joint Commission
notification of survey event Connect extranet site.
Verify identity of the surveyor(s) Check the picture ID to ensure that they are
from The Joint Commission. Also log into
your Joint Commission Connect extranet site
to validate the surveyor’s identity, when
possible.
Determine where they will meet Location:
with your team
Note: Please download the entire Survey Activity Guide for additional information on how to prepare for
survey.
The Survey Document List and Survey Activities list appears on the pages that follow. Please review
them to assist you in preparing for your survey. The Survey Activities list includes the potential survey
activities that can occur on an accreditation survey, including the suggested duration, and suggested
timing for these activities. This information will allow your organization to begin identifying participants that
need to be involved in the survey. The Survey Activities list includes a column for your organization to use
for recording participant names, possible meeting locations, times that could conflict with participant
availability, or any other notes. Please work with your surveyor(s) to confirm the best day(s) and/or time(s)
for specific survey activities to take place. Contact your Account Executive with any questions related to
this information.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 8Survey Document List
As an Ambulatory Care or Office-Based Surgery organization, you will need to have the following
available for the surveyor(s) to review (depending on the type of survey or setting) during the Surveyor
Arrival and Preliminary Planning Session.
Please note that this is not intended to be a comprehensive list of documents that may be requested
during the survey. Surveyor(s) may need to see additional documents to further explore or validate
observations or discussions with staff.
Note: The 12-month reference in the following items is not applicable to initial surveys.
Item Items Comments/
No. Notes
1 Performance / Quality Improvement Data from the past 12 months
2 Infection Control surveillance data from the past 12 months
3 Infection Control Plan
4 Environment of Care management plans and annual evaluations
5 Meeting minutes pertaining to Environment of Care topics for the 12-months
prior to survey, if applicable
6 Organization chart
7 A map of the organization, if available
8 List of all sites that are eligible for survey
9 List of locations where services are provided, including anesthetizing locations
10 List of locations where high-level disinfection and sterilization is in use
11 Any reports or lists of patient appointment schedules or surgery schedules for
each day of the survey
12 A list of contracted services
13 Name and extension of key contacts who can assist surveyors in planning
tracer selection
14 Most recent culture of safety and quality evaluation data
For Ambulatory Surgery Centers (ASC) Deemed Status Surveys:
15 List of surgeries from the past six months
16 List of cases in the past 12-months, if any, where the patient was transferred
to a hospital or the patient died (Note: The 12-month time frame for this
data applies to all ASC organizations seeking deemed status, whether
undergoing a Joint Commission initial survey or resurvey.)
17 Documents related to the infection control program (e.g., description, policy,
procedures, surveillance data)
18 Infection Control Surveyor Worksheet
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 9Documents Related to CMS Emergency Management Final Rule applies to Deemed Ambulatory
Surgical Centers, Rural Health Clinics, and Federally Qualified Health Centers
Note: Document formats may vary, and many of the documents listed below may be included in the
Emergency Management Plan.
19 Prioritized Potential Emergencies (Hazard Vulnerability Analysis)
20 Emergency Management Plan
21 Documentation of annual review and update of Emergency Management Plan,
including communication plans
22 Continuity of Operations Plan
23 Documentation of completed/attempted contacts with contact local, state,
tribal, regional, federal EM officials in organization’s service area
24 Annual training
25 Patient evacuation procedures
26 Tracking system for patients sheltered on-site and patients relocated to
alternate site
27 Integrated EM system risk assessments, plan, and annual review
For Bureau of Primary Health Care (BPHC) surveys:
28 List of Board of Directors membership, including the user/patient/consumer
status, occupational/areas of expertise, geographic location, and special
population representation
29 Board minutes (past 12 months on all surveys); annual Uniform Data System
(UDS) report
30 Most recent BPHC Notice of Grant Award (with any conditions or management
assessment items)
31 Items from most recent BPHC Grant Application: Health Care Plan, Scope of
Services; Overall Summary (if available)
32 Health Center’s bylaws, strategic plan, and needs assessment
For End Stage Renal Disease (ESRD) surveys:
33 Life Safety drawing of the facility (current and accurate drawings of the facility
w/fire safety features and related square footage noted)
34 List of current patients by name, separated into modalities
35 Current in-center hemodialysis patient schedule by days & shifts with any
isolation patients identified (seating chart or assignment sheet)
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 1036 List of dialysis patients who have been designated as “unstable” for any month
in the past 3 months, including reason for unstable and month
37 List of all dialysis patients who were involuntarily discharged (not transferred to
another outpatient dialysis facility) from this facility in the past 12 months
38 List of all discharged dialysis patients categorized as “lost to follow up” (i.e. not
transferred out or discontinued dialysis) for past 12 months
39 List of residents of long-term care (LTC) facilities for whom the organization is
providing onsite dialysis treatment
40 List of dialysis patients receiving services from the facility who were admitted
for inpatient care within the past 6 months
41 Infection logs for past 6 months
42 Policies and procedures for dialysis patient care, including: Water and
dialysate testing, emergency patient response, infection control, and dialyzer
reprocessing/reuse, if applicable
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 11Survey Activities
Duration
Activity Name Scheduling Guidelines Notes
Activity
Surveyor Arrival and Preliminary
Planning 30-60 minutes 1st day, upon arrival
Opening Conference 15 minutes 1st day, as early as possible
Orientation to Your Organization 30-60 minutes 1st day, as early as possible
Individual Tracer activity
occurs throughout the
Individual Tracer 60-120 minutes survey; the number of
individuals who surveyors
trace varies by organization
At a time negotiated with the
Lunch 30 minutes
organization
End of each day except last;
Issue Resolution OR Surveyor
30 minutes can be scheduled at other
Planning/Team Meeting
times as necessary
Start of each survey day
except the first day; can be
Daily Briefing 15-30 minutes
scheduled at other times as
necessary
After some individual tracer
Competence Assessment and activity has occurred; at a
30-60 minutes
Credentialing & Privileging time negotiated with the
organization
After some individual tracer
Environment of Care and activity has occurred; at a
45-90 minutes
Emergency Management time negotiated with the
organization
After some individual tracer
activity has occurred; at a
time negotiated with the
organization. If this is the
System Tracer – Data only system tracer taking
30-90 minutes
Management place during survey, the
topics of Infection Control
and Medication Management
will be covered in this
discussion.
Towards the middle or end
of survey at a time
Leadership 60 minutes
negotiated with the
organization
Surveyor Report Preparation 60-120 minutes Last day of survey
CEO Exit Briefing 10-15 minutes Last day of survey
Last day, final activity of
Organization Exit Conference 30 minutes
survey
Occurs on all Ambulatory
Surgical Center surveys,
both deemed status and
non-deemed status; to
evaluate compliance with the
Life Safety Code Building Ambulatory Health Care
45-90 minutes
Assessment Occupancies chapters of the
Life Safety Code® (NFPA
101-2012) and Health Care
Facilities Code NFPA 99-
2012;
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 12Duration
Activity Name Scheduling Guidelines Notes
Activity
Also occurs on surveys
where four or more
individuals are
simultaneously rendered
incapable of self-
preservation
This focused tracer occurs
Program Specific Tracer – during time designated for
60-120 minutes
Continuity of Care Individual Tracer Activity.
After some individual tracer
activity has occurred; topic
may be covered during the
System Tracer – Infection Control 30-60 minutes
Data Management system
tracer depending on the
length of survey
After some individual tracer
activity has occurred; topic
System Tracer – Medication may be covered during the
30-60 minutes
Management Data Management system
tracer depending on the
length of survey
After some individual tracer
Bureau of Primary Health Care
activity has occurred; at a
Surveys only -- Governance 45-60 minutes
time negotiated with the
Discussion
organization
After some individual tracer
Bureau of Primary Health Care
activity has occurred; at a
Surveys only – Clinical Leadership 60 minutes
time negotiated with the
& Staff Discussion
organization
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 13DURING THE SURVEY Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 14
Applicable Programs
AHC and OBS
Surveyor Arrival and Preliminary Planning
Session
Participants
Suggested participants include organization staff and leaders as identified in the Pre-survey Planning
process.
Duration
The surveyor(s) will arrive between 7:45-8:00 a.m. unless business hours, as reflected in the survey
application, indicate that your organization opens at a later time. The suggested duration of the
preliminary planning session is approximately 30 to 60 minutes.
Surveyor Arrival Activities
• Notify key organization members as identified in the pre-survey planning session of the surveyor(s)
arrival.
• Validate that the survey is legitimate by accessing your Joint Commission Connect extranet site. A
staff member in your organization with a login and password to your Joint Commission Connect
extranet website will follow through with this by:
o Accessing the Joint Commission’s website at www.jointcommission.org
o Under ‘Action Center,’ log in The Joint Commission Connect extranet site
o Enter a login and password
o If you cannot access The Joint Commission Connect extranet site to validate the survey
or surveyors, call your Account Executive
Your organization’s Joint Commission Connect extranet site contains the following information
(posted by 7:30 a.m. on the morning of your survey):
o Notification of scheduled Joint Commission event authorizing the surveyor’s presence for
the unannounced survey
o Surveyor name(s), picture and biographical sketch
o Scheduled survey dates
• If you have not already downloaded a copy of your survey agenda, do so at this time.
• Begin gathering and present documents as identified in the Survey Document List applicable to your
program(s). Surveyors will start reviewing this information immediately.
Overview
Surveyor(s) will need a workspace they can use as their “base” for the duration of the survey. This area
should have a telephone, internet access, and access to an electrical outlet. The surveyor(s) will need
the name and phone number of a key contact person who will assist them in planning for the survey and
their tracer selections.
After the surveyor(s) identification has been verified, they will immediately begin planning for tracer
activity by reviewing the documents you provide them (refer to the Survey Document List on the
preceding pages). The surveyor(s) will begin discussing the focus of the survey with the other surveyors
(when applicable). If documents are not available for surveyors to review during this session, they will
proceed to areas where care, treatment, or services are provided and begin individual tracer activity.
For complex organizations surveyed under more than one accreditation manual or for more than one
service under one accreditation manual, surveyors review information from all accredited programs. It is
important to have documents available at this session for each program being surveyed. See appendices
for program documentation lists and sessions.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 15For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and are
using The Joint Commission for ADI certification
• Organizations will receive no notice of the survey event prior to surveyor arrival
For organizations electing Primary Care Medication Home (PCMH) certification
• Provide the surveyor with the "Primary Care Medical Home Self-Assessment Tool." If you have
completed the PCMH self-assessment tool, provide it to the surveyor(s). A copy of the tool can be
obtained on The Joint Commission’s ambulatory care section of the website.
For Ambulatory Surgery Centers (ASC) Deemed Status Surveys
• Two active patients are required at the time of survey, preferably during Day 1.
• Surveyors will observe at least one surgical procedure from the pre-operative phase through to the
recovery room and discharge phase during the survey. A schedule of surgical procedures is needed
for planning this observation.
• Surveyors will use the list of surgeries from the past six months to select a sample of closed medical
records for review. At a minimum, surveyors will:
o Select 20 records for a facility with a monthly case volume exceeding 50.
o Select at least 10 records for lower volume ASCs.
The sample size may be expanded as needed.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 16Applicable Programs
AHC and OBS
Opening Conference
Participants
Suggested participants include members of the governing body and senior leadership (representing all
accredited programs/services). Attendees should be able to address leadership’s responsibilities for
planning, resource allocation, management, oversight, performance improvement, and support in carrying
out your organization’s mission and strategic objectives. Leaders of the medical staff should also
participate, when applicable.
Duration
The duration of this session is approximately 15 minutes. Immediately following this session is the
Orientation to Your Organization. If possible, designate a room or space that will hold all participants and
will allow for an interactive discussion. Inform surveyor(s) at this time of any agenda considerations that
may impact the activities for the day.
Overview
During this session, the surveyor(s) will:
• Describe the structure of the survey
• Answer questions your organization has about the survey
• Review your organization’s expectations for the survey
• For PCMH Certification Surveys: Explain that the survey will include an evaluation of compliance
with PCMH-specific requirements.
The surveyor(s) will introduce themselves and describe each component of the survey agenda. The
surveyor(s) will describe the System Tracers they will conduct. It is important for you to discuss and
review your organization’s expectations for the onsite survey with the surveyor(s). Questions about the
onsite visit, schedule of activities, availability of documents or people, and any other related topics should
be raised at this time. Surveyors will also take time to introduce your organization to the revised
Clarification procedures and new SAFER™ reporting process.
Note: When a situation is identified that could be a threat to health and safety, surveyors contact The Joint
Commission administrative team. The Joint Commission will either send a different surveyor to investigate
the issue or the surveyor on site will be assigned to investigate. Investigations include interviews,
observation of care, treatment, and service delivery, and document review. Your cooperation is an
important part of this process. Surveyors will discuss the findings with the Joint Commission administrative
team and outcomes will be communicated to your organization when a decision is reached.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 17Applicable Programs
AHC and OBS
Orientation to Your Organization
Participants
Suggested participants are the same as those in the Opening Conference. They include members of the
governing body and senior leadership (representing all accredited programs/services). Attendees should
be able to address leadership’s responsibilities for planning, resource allocation, management, oversight,
performance improvement, and support in carrying out your organization’s mission and strategic
objectives.
Duration
The suggested duration of this session is approximately 30-60 minutes.
Overview
During this session, the surveyor(s) become acquainted with your organization. They learn how your
organization is governed and operated and explore your organization’s performance improvement
process. There is no need to prepare a formal presentation. This session is an interactive discussion
and may be combined with the Opening Conference.
Governance and operations-related topics for discussion include:
• Organization’s mission, vision, goals, and strategic initiatives
• Organization structure
• Operational management structure
• Information management, including the format and maintenance of medical records
• Contracted services and performance monitoring of contracted services
• Patient safety initiatives
• National Patient Safety Goals (July 1 ,2019 for Medical Centers only: New and revised
requirements at NPSG.03.05.01 related to anticoagulation therapy)
• Community involvement
• Leader’s role in emergency management planning
• Organization activities related to risk awareness, detection and response as it relates to cyber
emergencies
• Cleaning, disinfection and sterilization processes
• As applicable to the organization’s services: Pain assessment, pain management and safe opioid
prescribing
• For providers of imaging services, including fluoroscopy: scope, types, locations, and safety
• For PCMH Certification Surveys: identify eligible sites
Discussion topics include:
• Leaders’ processes for identification and monitoring of potential risk areas
• Leaders’ approach to completing the Focused Standards Assessment (FSA) Tool and methods
used to address areas needing improvement (resurveys only)
• Management and leadership’s oversight and other responsibilities
Senior Leadership Role in Improving Performance discussion topics may include:
• How leaders set expectations, plan, assess, and measure initiatives to improve the quality of
services
• Organization approach to safety, including selection of Proactive Risk Assessment topics,
resulting improvements, and Board/Governance involvement in safety issues
• Provision of staff and resources including time, information systems, data management, and staff
training
Note: Surveyor(s) will request examples of performance improvement initiatives including
evidence that performance was achieved and sustained.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 18Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 19
During this session, the surveyors will:
For PCMH Certification Surveys
• Ask about the scope of services provided, (i.e., acute, chronic and urgent care) and the types of
services available, (i.e., pediatrics, obstetrics/gynecology, behavioral health, dentistry)
• Determine how the organization uses health information technology (HIT) to support continuity of
care, and the provision of comprehensive and coordinated care
• The surveyors will also ask leaders to describe processes and infrastructure in place to support
the provision of coordinated and comprehensive care, including:
▪ 24/7 patient access to prescription renewal requests, test results, clinical advice for urgent
health care needs, and appointment availability
▪ Addressing patient urgent health care needs 24/7
▪ Identification of interdisciplinary team members
▪ Use of an electronic prescribing process and in what locations/areas; and, if the process is
not in use throughout the organization ask about plans to expand use
▪ The type of providers that serve in the role of primary care clinician
▪ Any sites that have non-physicians serving in the role of primary care clinician
▪ Processes in place to support patient selection of a primary care clinician
For ASC Deemed Status Surveys
• Verify that the governing body has full legal responsibility for determining, implementing, and
monitoring policies governing the ASC’s total operation
• Explore the operational management structure
• Identify who is responsible for directing nursing services and will ask if this individual a registered
nurse
• Request and review governing body meeting minutes or other documents to verify governing
body oversight and accountability for the ASC’s Quality Assurance Performance Improvement
(QAPI) program. This review can occur during the Surveyor Planning Session or Special Issue
Resolution.
• If applicable, select a sample of contractors working with the ASC and request to see
documentation of the most recent contractor performance assessment conducted by the ASC.
This review can occur during the Surveyor Planning Session or Special Issue Resolution.
• Surveyors will observe at least one surgical procedure during the survey. Be prepared to provide
a schedule of surgical procedures.
• Ask about the types of radiologic procedures that are performed in the ASC, and explore whether
they are limited to those that are integral to the procedures performed
• Explore whether the ASC has designated someone to be responsible for oversight of radiologic
services
For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and are
using The Joint Commission for ADI certification
• Identify who serves as the medical director or supervising physician for advanced diagnostic
imaging services.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 20Applicable Programs
AHC and OBS
Individual Tracer Activity
Participants
Suggested participants include staff and management involved in the individual’s care, treatment, or
services.
Duration
The duration of individual tracer activity varies but typically is 60-120 minutes.
Overview
During tracers, the surveyor(s) will evaluate your organization’s compliance with standards as they relate
to the care, treatment, or services provided to patients.
The majority of survey activity occurs during individual tracers. The term “individual tracer” denotes the
survey method used to evaluate your organization’s compliance with standards related to the care,
treatment, or services provided to a patient. Most of this survey activity occurs at the point where care,
treatment, or services are provided.
Initially, the selection of individual tracer candidates is based on your organization’s clinical services as
reported in your e-application and the general risk areas identified for the accreditation program which are
listed in the Intra-Cycle Monitoring (ICM) Profile. Surveyors will also consider any organization-specific
risk areas listed in the ICM Profile. As the survey progresses, the surveyor(s) may select patients with
more complex situations, who are identified through the system tracers and whose care crosses services.
The individual tracer begins in the program where the patient and his/her record of care are located. The
surveyor(s) starts the tracer by reviewing a record of care with the staff person responsible for the
individual’s care, treatment, or services. The surveyor(s) then begins the tracer by:
• Following the course of care, treatment, or services provided to the patient from entry to the
organization through end of episode of care.
• Assessing the interrelationships between disciplines, departments, programs, services, or units
Identifying issues that will lead to further exploration in the system tracers or other survey
activities such as Environment of Care and Leadership Sessions
Surveyor(s) will try to protect patient confidentiality and privacy and they will seek the assistance of your
staff in this effort. Surveyor(s) may use multiple patient records during an individual tracer. The record
helps the surveyor follow the care, treatment, or services provided by the organization to the patient.
The surveyor(s) may arrive in a setting/unit/program/service and need to wait for staff to become
available. If this happens, the surveyor(s) will use this time to evaluate environment of care issues or
observe the care, treatment, or services being provided.
If there are multiple surveyors conducting the survey, they will make every effort to avoid visiting areas at
the same time. Surveyors will try to minimize multiple visits to the same location, although they will need
to follow the patient to the areas where services were provided.
During the individual tracer, the surveyor(s) will observe the following at a minimum:
• Care, treatment or services being provided to patients by clinicians, including physicians
• The medication process (e.g., preparation, dispensing, administration, storage, control of
medications)
• Infection control issues (e.g., techniques for hand hygiene, sterilization of equipment, disinfection,
food sanitation, and housekeeping)
• The process for planning care, treatment or services
• The environment as it relates to the safety of patients and staff
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 21• For ASC Deemed Status Surveys: Surveyors will observe at least one surgical procedure
during the survey
During the individual tracer, the surveyor(s) will interview staff about:
• Intradepartmental and interdepartmental communication for the coordination of care, treatment or
services. (e.g., hand offs)
• The use of data
• Patient flow through the organization
• National Patient Safety Goals (July 1 ,2019 for Medical Centers only: New and revised
requirements at NPSG.03.05.01 related to anticoagulation therapy)
• Patient education
• Orientation, education, and competency of staff
• The IM systems they use for care, treatment and services (paper, fully electronic or a combination
of the two) and about any procedures they must take to protect the confidentiality and integrity of
the health information they collect
o Back up procedures they’ve been instructed to use if the primary system is unavailable
o If internet-connected health information, equipment, or devices are used in care, treatment, or
service, staff may be asked to describe their access procedures (passwords, authentication,
etc.), confidentiality measures, and instructions on down-time procedures
o How they approach risk awareness, detection and/or response as it relates to potential cyber
emergencies
• As applicable to the organization’s services: Pain assessment, pain management and safe opioid
prescribing initiatives and resources made available by the organization; Prescription Drug
Monitoring Database and criteria for accessing
• As applicable to the organization’s services, the surveyor may select a patient receiving care,
treatment, or services related to the organization’s annual antimicrobial stewardship goal and
discuss: Antimicrobial stewardship guidelines the organization is using and staff training and
education about appropriate prescribing practices.
• Other issues
During the individual tracer, the surveyor(s) will speak with available licensed independent practitioners
about:
• Organization processes that support or may be a barrier to patient care, treatment, or services
• Communications and coordination with other licensed independent practitioners (hospitalists,
consulting physicians, primary care practitioners)
• As applicable to the organization’s services: Pain assessment, pain management and safe opioid
prescribing initiatives and resources made available by the organization; Prescription Drug
Monitoring Database and criteria for accessing
• As applicable to the organization’s services, the surveyor may select a patient receiving care,
treatment, or services related to the organization’s annual antimicrobial stewardship goal and
discuss: Antimicrobial stewardship guidelines the organization is using and provider training and
education about appropriate prescribing practices.
• Discharge planning, or other transitions-related resources and processes available through the
organization
• Awareness of roles and responsibilities related to the Environment of Care, including prevention
of, and response to incidents and reporting of events that occurred
During the individual tracer, the surveyor(s) will interview patients and their families about:
• Coordination and timeliness of services provided
• Education, including discharge instructions
• Response time when a call bell is initiated or alarms ring, as warranted by care, treatment or
services
• Perception of care, treatment or services
• Staff observance of hand-washing and verifying patient’s identity
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 22• Understanding of instructions (e.g., diet or movement restrictions, medications, discharge and
provider follow-up), as applicable
• As applicable to the organization’s services: How staff involved them in their pain management
plan of care, what their pain management plan of care includes (non-pharmacologic,
pharmacologic or a combination of approaches)
• Rights of individuals served/patients/residents
• For ASC Deemed Status Surveys: Receipt of patient rights information
• Other issues
For PCMH Certification Surveys: The surveyor(s) will select a patient that has had a test ordered or a
referral issued. During the individual tracer, the surveyor(s) will interview staff about:
• How staff track and follow-up on test results and referral, validated through a review of clinical
records
• Whether recommendations or results from referrals are available to the primary care clinician
• Whether staff can identify the members of the patient's interdisciplinary team
• Whether staff can describe, how the interdisciplinary team works to collaborate on patient care
• Whether staff can describe how patient self-management goals are incorporated into the
treatment plan; surveyors may ask to see examples in the clinical record
• How they assess patient health literacy
During the individual tracer, the surveyor(s) will interview patients and their families about:
• Information provided to them to help select a primary care clinician
• Information provided to them about how the organization functions and the available services
• Directions they received about obtaining urgent care after the office/clinic is closed and if they
have ever needed such care
For ASC Deemed Status Surveys:
During the individual tracer, the surveyor(s) will interview patients and their families about:
• How and when the organization provided them with patient rights information --verbally and in
writing and prior to the start of their surgical procedure
• Whether they received financial disclosure information in writing
• Whether they were provided with written information concerning organization policies on advance
directives prior to the start of their surgical procedure. This includes a description of applicable
state health and safety laws and a copy of the official state advance directive forms
The surveyor(s) will also ask about:
• Processes in place to ensure safe handling of hazardous materials and waste
• Radiation exposure monitoring procedures
• The ASC’s timeframe for record maintenance
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 23Applicable Programs
AHC and OBS
Special Issue Resolution
Participants
As requested by the surveyor or survey team
Duration
The duration is approximately 30 minutes and scheduled toward the end of each day except the last for
surveyors to conduct either Special Issue Resolution or engage in Surveyor Planning or Team Meeting
activity. The surveyor will inform your organization’s contact person what activity they will be conducting.
Overview
This time is available for surveyors to explore any issues that may have surfaced during the survey and
could not be resolved at the time they were identified (staff unavailable for interview, visit to another
location required, additional file review required, etc.). Depending on the circumstances, this may
include:
• The review of certain policies and procedures
• The review of additional patient records to validate findings
• Discussions with staff to obtain additional information or clarification
• Review of staff and credentials files
• Review of data, such as performance improvement results
• Other issues requiring more discussion
The surveyor(s) will inform your organization’s contact person about any documentation needed, any staff
who they would like to speak with, or locations they want to visit.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 24Applicable Programs
AHC and OBS
Surveyor Planning / Team Meeting
Participants
None
Duration
The duration for this session is 30 minutes.
Overview
For surveys lasting more than one day, 30 minutes is scheduled toward the end of each day except the
last for surveyors to conduct either Special Issue Resolution or engage in Surveyor Planning or Team
Meeting activity. The surveyor will inform your organization’s contact person of the activity they will be
conducting.
Before leaving the organization, the surveyor(s) will return organization documents to the survey
coordinator / liaison. If surveyor(s) have not returned documents, your organization is encouraged to ask
surveyor(s) for them prior to their departure.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 25Applicable Programs
AHC only
Daily Briefing
Participants
Suggested participants include representative(s) from governance, the CEO/Administrator or Executive
Director, the Joint Commission accreditation contact, and other key contact individuals identified by staff.
Duration
The duration for this session is approximately 15 to 30 minutes, beginning on Day 2.
Overview
During this session, the surveyor(s) will briefly summarize the survey activities completed the previous
day and communicate observations according to standards areas that may or may not lead to findings.
Surveyor(s) may ask to hold a daily briefing before concluding activity on the first day, depending on
circumstances. If a surveyor cannot participate in this session because he or she is surveying at a
remote location, you may be asked for assistance with setting up a conference call to include all
surveyors and appropriate staff.
The surveyor(s) will make general comments regarding significant issues from the previous day, note
potential non-compliance, and emphasize performance patterns or trends of concern that could lead to
findings of non-compliance. The surveyor(s) will allow you the opportunity to provide information that they
may have missed or that they requested during the previous survey day. You may also present
surveyors with information related to corrective actions being implemented for any issues of non-
compliance. Surveyor(s) will still record the observations and findings but will include a statement that
corrective actions were implemented by the organization during the onsite survey.
Your organization should seek clarification from the surveyor(s) about anything that you do not
understand. Note that the surveyor(s) may decide to address your concerns during a Special Issue
Resolution Session, later in the day. It is important for you to seek clarification if you do not understand
anything that the surveyors discuss.
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 26Applicable Programs
AHC and OBS
Competence Assessment and Credentialing
& Privileging
Participants
Suggested participants include staff responsible for the human resources processes; orientation and
education of staff; assessing staff competency; assessing licensed independent practitioner and other
credentialed practitioner competency.
Duration
The duration for this session is 30-60 minutes.
Applicability
This session addresses staff competence and the credentialing and privileging processes for licensed
independent practitioners, when relevant.
Overview
During this session, the surveyor(s) will:
• Learn about your organization’s competence assessment process for staff, licensed independent
practitioners, and other credentialed practitioners
• Learn about your organization’s orientation, education, and training processes as they relate to staff,
licensed independent practitioners, and other credentialed practitioners
Inform the surveyor(s) of your process for maintaining competency records. The review of files is not the
primary focus of this session; however, the surveyor(s) verifies process-related information through
documentation in staff or credential files. The surveyor(s) identifies specific staff, licensed independent
practitioners, or other credentialed practitioners whose files they would like to review.
The surveyor(s) discusses the following topics:
• Internal processes for determining compliance with policies and procedures, applicable law and
regulation, and Joint Commission standards
• Methods used to determine staffing adequacy, frequency of measurement, and what has been
done with the results
• Performance improvement initiatives related to competency assessment for staff, licensed
independent practitioners, and other credentialed practitioners
• Orientation of staff, licensed independent practitioners, and other credentialed practitioners to
your organization, and/or job responsibilities
• Experience, education, and abilities assessment
• Ongoing education and training
• Competency assessment, maintenance, and improvement
• Competency assessment process for contracted staff, as applicable
• Process for granting of privileges to licensed independent practitioners
• As applicable to the organization’s services: Any educational materials that address the
organization’s annual antimicrobial stewardship goal and strategies promoting appropriate
prescribing practices.
• Other topics and issues discovered during the tracer activity
During this session, the surveyors will:
For ASC Deemed Status Surveys:
• Review a sample of staff records for non-physician licensed practitioners providing care in the ASC
for evidence of:
o Current licenses in good standing
o Qualifications
o Periodic performance evaluation in accordance with the ASC’s policies
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 27• Review the staff files of contract staff to verify credentials, privileges, evidence of training, as
applicable
• Review the qualifications of individuals authorized to deliver anesthesia in the ASC, to determine if
they are consistent with regulatory requirements.
• Verify that the individuals performing procedures have privileges granted by the governing body.
• Review a sample of credentials files for medical staff (See Sampling Table 1) who have been granted
privileges for the following:
o state licensure, registration, or state certification as applicable
o training and pertinent experience
o scope of privileges granted
o evidence that they are legally and professionally qualified to exercise privileges granted
o evidence of reappraisal within the timeframe specified in the ASC’s policy
• Review the personnel file of the individual designated as responsible for oversight of all radiologic
services
• Review personnel files of selected practitioners and staff for their qualifications and competency
assessments related to assigned duties
• Review staff record of the person responsible for directing infection control activities for evidence of
training in infection control
For PCMH Certification Surveys:
• Review the staff or credentials files of one or more clinicians serving in the role of primary care
clinician (PCC) for evidence of broad-based education and experience in the provision of primary
care.
For providers of Advanced Diagnostic Imaging (ADI) who serve Medicare beneficiaries and are
using The Joint Commission for ADI certification:
• Review the staff/credential file of the medical director or supervising physician of advanced
diagnostic imaging services for evidence of training in advanced diagnostic imaging services
obtained through:
o residency program
o experience
o continuing medical education courses
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 28Applicable Programs
AHC and OBS
Environment of Care and
Emergency Management Session
Participants
Suggested participants include individuals familiar with the management of the environment of care and
emergency management in all major areas within your organization. This may include the safety officer,
security management coordinator, facility manager, building utility systems manager, IT representative,
and the person responsible for emergency management.
Duration
The duration of this session is approximately 45-90 minutes depending on the type of organization,
services provided and facilities, and will consist of two parts: Environment of Care/Emergency
Management discussion and Environment of Care tracer.
Overview
During this session, the surveyor will assess your organization’s degree of compliance with relevant
standards and identify vulnerabilities and strengths in your organization’s environment of care
management and emergency management processes.
The first part of the session is a group discussion that takes approximately 70% of the allotted time. The
surveyor is not the primary speaker because it is not intended to be an interview. He or she listens to the
discussion, of the Environment of Care risk categories as indicated in the matrix below, and safety data
analysis and actions taken by your organization.
In the remaining time, the surveyor observes and evaluates your organization’s performance in managing
a particular risk or management process in the environment of care. The management process or risk
selected for observation is based on the environment of care documents previously reviewed, observation
by other surveyors, and knowledge gained during the group discussion of this session.
Environment of Care Discussion and Emergency Management (Approximately 70% of session
time) – Be prepared to discuss how the various Environment of Care risk categories1 and construction
activities, when applicable, are addressed in each of the following six management processes.
IMPROVE PLAN
MONITOR
EC Risk
Management Cycle
RESPOND
TEACH
IMPLEMENT
Plan
• What specific risks related to its environment of care have been identified by your organization?
1 The environment of care risk categories include: general safety and security, hazardous materials and waste, fire
safety, medical/laboratory equipment, and utilities (see matrix on the next page for applicability of risk categories to
each accreditation program).
Copyright: 2021 The Joint Commission AHC/OBS Organization Guide January 2021 29You can also read
