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Joint Commission Standards and the Survey Process

The Joint Commission provides several accreditation programs based on the type of health care organization or facility. These programs include:

  • Ambulatory Care (AHC)
  • Behavioral Health (BHC)
  • Critical Access Hospitals (CAH)
  • Home Care (OME)
  • Hospitals (HAP)
  • Laboratories
  • Long-Term Care and Medicare/Medicaid Certification-Based Long-Term Care (LTC)
  • Office-Based Surgery (OBS)

Each accreditation program has a specific set of standards. The standards for hospitals are provided in the Comprehensive Accreditation Manual for Hospitals (CAMH). Each standard has one or more elements of performance (EPs). Many of the standards and EPs appear in the accreditation programs for several facility types. Others may be unique to a particular accreditation program.

The standards are organized into functional chapters. For example, following are the chapters for the Hospital Accreditation Program:

  • Accreditation Participation Requirements (APR)
  • Environment of Care (EC)
  • Emergency Management (EM)
  • Human Resources (HR)
  • Infection Prevention and Control (IC)
  • Information Management (IM)
  • Leadership (LD)
  • Life Safety (LS)
  • Medication Management (MM)
  • Medical Staff (MS)
  • Nursing (NR)
  • Provision of Care, Treatment, and Services (PC)
  • Performance Improvement (PI)
  • Record of Care, Treatment, and Services (RC)
  • Rights and Responsibilities of the Individual (RI)
  • Transplant Safety (TS)
  • Waived Testing (WT)

Chapters that have the most significant impact on the health care physical environment are these:

  • Life Safety (LS)
    LS is based on the 2000 edition of NFPA 101: Life Safety Code®.
  • Environment of Care® (EC)
    EC includes the following functional areas:
    • Safety
    • Security
    • Smoking
    • Hazardous materials and waste
    • Fire safety
    • Medical equipment
    • Utility systems (building systems, including emergency power and medical gas systems)
    • Provision of a safe, functional environment
  • Emergency Management (EM)
    EM includes the following functional areas:
    • Planning
    • Emergency operations plan
    • Managing operations through an emergency
    • Evaluating effectiveness

Other chapters, such as Human Resources, Infection Control, and Leadership may also impact the physical environment.

An on-site survey focuses on evaluating compliance with the Joint Commission standards.

To demonstrate its compliance with these standards, each surveyed organization must develop, implement, and maintain a plan and processes that address specific requirements in the standards, including:

  • Emergency Management
  • Life Safety
  • Fire safety
  • Safety and Security Management
  • Hazardous Materials and Waste Management
  • Medical Equipment Management
  • Utilities Management

In addition to standards, the Joint Commission periodically issues Sentinel Event Alerts. (Click here to access an index to Joint Commission Sentinel Event Alerts.) These are typically prepared in response to an adverse event reported by a hospital.

The Joint Commission also issues National Patient Safety Goals that are based on sentinel events or trends revealed in the survey process. These goals are updated annually, with new goals added and goals removed where significant improvement has been noted. (Click here to view the current National Patient Safety Goals.)

The Joint Commission survey process continues to evolve along with its standards. In the past, health care organizations focused on the scheduled survey, often concentrating on “cramming” to prepare for the survey. In a small percentage of cases, an unannounced survey was conducted, but the vast majority of surveys were conducted at three-year intervals.

Today, all surveys are unannounced, and organizations are encouraged to maintain a state of continuous compliance. When the surveyors come through the door, key managers, directors, or members of the administrative staff may not be on-site that day. The unannounced survey process emphasizes the need for training and involvement of staff in managing the patient care environment.

The size and composition of the Joint Commission survey team varies according to the size of the organization and types of services being surveyed. However, the team includes some combination of nurse, physician, and/or administrative surveyor. A life safety code specialist is also on the survey team for all hospitals. One of the surveyors will likely focus on Emergency Management at some point during the survey; however, any surveyor on the team can ask questions and make observations related to emergency management and operations.

The Life Safety Code Specialist
The life safety code specialist is present for two days at facilities of more than 750,000 square feet and one day for facilities under 750,000 square feet. Typically, the specialist is at the facility while the survey team is there, but occasionally he or she may come at a different time, either before or after the rest of the team.

The life safety code specialist focuses on compliance with the Life Safety Code, the Statement of Conditions (SOC), medical gas system requirements, and certain Environment of Care standards. The specialist will tour the building and may want to tour construction sites.

Critical Access Hospital Surveys
Critical access hospitals are surveyed for compliance with the Joint Commission Critical Access Hospital Standards. At these hospitals, the life safety code specialist usually surveys Emergency Management and all of the Environment of Care areas as well as for Life Safety compliance.

The American Society for Healthcare Engineering of the American Hospital Association
155 N. Wacker Drive, Suite 400. Chicago, IL 60606
Phone: 312-422-3800 | Fax: 312-422-4571