Joint Commission Survey: Readiness Checklist (2024-2025)

A Joint Commission Survey can happen without much notice, so it’s never too early to make sure that your facility is ready to undergo a review. An understanding of the Joint Commission Survey is a good starting point, but when you’re ready to take actionable steps, the Joint Commission Survey Readiness Checklist (2024-2025) is a helpful, all-in-one resource that you can access at any time.

To move you along this process, this guide will detail what the readiness checklist is and how it can help prepare you for your next survey.

What Is the Joint Commission Readiness Checklist?

The Joint Commission Survey Readiness Checklist (2024-2025), also known as the Survey Activity Guide, is an online document created by The Joint Commission (JCAHO) to help prepare facilities for their next survey visit. This checklist walks facility leaders through everything they need to know for the day of the survey, ranging from how to greet the administrators to what types of documentation should be shown.

Different types of facilities will follow slightly different checklists and Joint Commission survey schedules, all of which can be found directly on The Joint Commission’s resource site. Care and safety standards may change from year to year, so it can help to look at the most updated version. The Joint Commission Survey Readiness Checklist 2024 is now available, highlighting what’s been updated since 2023.

Summary of Readiness Checklist Items

The Joint Commission Survey Readiness Checklist (2024-2025) is a comprehensive document, so it can look a bit daunting upon your first read. To warm you up to the contents, the following overview describes the sections of the checklist and what you’ll need for each one.

Remember, Joint Commission checklist items can vary by facility and this is just a broad overview of what information is outlined inside. It’s important to review the full, corresponding facility guide once you’re ready for more specific details.

Surveyor Arrival and Orientation

Description

This section details what you should do once the Joint Commission surveyors arrive at your facility. Upon their arrival, you will generally be expected to greet the surveyors, check their identification cards, and be prepared to show any documentation that needs to be reviewed.

What You’ll Need To Prepare

• Up-to-date documents for your facility (full list in the Survey Activity Guide)
• Private space for surveyors to meet and reside in during the day
• Designated staff to orient surveyors to the layout of the facility

Care, Treatment, and Services

Description

Each Joint Commission survey checklist has sections describing how surveyors will assess the quality of care, treatment, and services delivered to patients. For these assessments, surveyors will interview and observe staff throughout the day. The specifics of what is evaluated will depend on the type of facility you’re running. At baseline, the surveyor will complete the Joint Commission tracer observation form, which analyzes each facility’s:

• Patient safety and lab testing protocols.
• Infection prevention and control practices.
• Medication administration processes.
• Health record documentation processes.
• Safety event reporting protocols.

What You’ll Need To Prepare

• Staff briefing session to relay what to expect during surveyor visit
• List of staff expected to be available (detailed in the Survey Activity Guide)
• Readily accessible performance monitoring data and quality indicator metrics

Competence, Credentialing, and Privileging

Description

There will be a few sections detailing how surveyors evaluate the way facilities keep their staff trained and credentialed. Surveyors will examine any competency assessments that need to be regularly taken by staff. Additionally, they’ll review the facility’s overall process of credentialing staff and appointing them to positions.

What You’ll Need To Prepare

• Accessible and up-to-date employee files
• Any documents detailing the employee bylaws
• Processes for credentialing, onboarding, and training for all employees and contractors

Life Safety Code

Description

This section explains how surveyors will review your facility’s Life Safety Code, which refers to the maintenance of any fire safety, emergency power, and gas/vacuum systems. Surveyors will assess these appliances and the general layout of your facility to ensure there’s nothing hazardous related to the structure of the building.

What You’ll Need To Prepare

• Ladder and flashlight for the surveyor touring facility rooms
• Maintenance staff to escort surveyor through locked areas
• Maintenance records for fire protection and suppression equipment, emergency power systems, and medical gas and vacuum systems

Emergency Management

Description

This section details how surveyors will assess your facility’s emergency management systems. This will mostly involve looking over any emergency planning documents and making sure everything is up to date. Surveyors will also assess how your plans align with local regulations and laws.

What You’ll Need To Prepare

• Updated documents detailing emergency and disaster planning (full list in the Survey Activity Guide)
• Policies and procedures for Interim Life Safety Measures (ILSMs)
• A list of recent emergencies/disaster incidents and an analysis of how your team executed the facility emergency operations plan

Leadership

Description

This section outlines how surveyors will take the time to get to know leadership of the facility and how they work to maintain structure and culture. This will involve an in-depth interview with selected leadership staff.

What You’ll Need To Prepare

• Private room for surveyors to meet with the leadership team
• A list of recent workplace wellness and quality improvement initiatives and how they impacted your patients and staff
• Processes for how you evaluate performance and provide employee feedback

Report Back and Exit Survey

Description

The last section of the Survey Activity Guide will detail how findings from the day are finalized and discussed with the facility leaders. Typically, there is a report back of findings and an exit survey with the CEO, if desired by the facility.

What You’ll Need To Prepare

• Notification to senior members of the executive team, informing them of the time and location for the exit survey meeting
• A designated conference room with table, power outlet, and a telephone
• Method for re-collecting all facility documents

The Joint Commission Survey Activity Guide (2024-2025) is updated with subsections highlighting changes from previous years. It’s important to note that the criteria assessed can change each year. Even if your facility met all requirements on last year’s Joint Commission checklist, 2024 updates may provide additional information that you should review in full for your next survey.

Are You Ready for Your Next Joint Commission Survey?

Now that you’ve learned what’s in the Joint Commission Survey Readiness Checklist (2024-2025), you may be looking for more ways to maintain standards of care and safety before your next survey. Our newsletter, created by our team of clinical and legal experts, is full of insights, tips, and guides to help your organization run smoothly.