Joint Commission Survey: Readiness Checklist (2023-2024)
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 (2023-2024) 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 (2023-2024), 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 through everything facility leaders 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, 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 for 2024 highlights what’s been updated since 2023.
Summary of Readiness Checklist Items
The Joint Commission Survey Readiness Checklist (2023-2024) is a comprehensive document, so it can look a bit daunting upon your first read. To warm you up to the contents, below is a broad overview describing the sections of the checklist and what you’ll need for each one.
Remember, checklist items can vary by facility and this is just a broad overview of what information is outlined inside. It is 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 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, staff will be interviewed and observed by surveyors throughout the day. The specifics of what is evaluated will depend on the type of facility you’re running. At baseline, this will likely involve the review of:
- Patient safety and lab testing protocols
- Infection prevention and control practices
- Medication administration processes
- Health record documentation processes
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)
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
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
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)
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 leadership team
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
- Surveyors will need a designated conference room with table, power outlet, and a telephone
Each year, the Survey Activity Guide is updated with subsections highlighting changes from previous years. So even if your facility met all criteria on last year’s Joint Commission checklist, 2023 guidelines may have been revised for 2024, which is why it’s important to review each update in full.
Are You Ready for Your Next Joint Commission Survey?
Now that you’ve learned what’s in the Joint Commission Survey Readiness Checklist (2023-2024), you may be looking for more ways to maintain standards of care and safety before your next survey. Sign up for IntelyCare’s free newsletter to read more comprehensive tips and guides that will help your facility run smoothly.