Questions Concerning the JCAHO Accreditation Survey Process

Note: If there are other questions or issues that you would like to see posted in this section, please contact Nancy Foster (

1. What is Shared Vision-New Pathways?

In fall 2002, the Joint Commission announced significant changes to its accreditation process for health care organizations. Shared Visions-New Pathways is an initiative that sharpens the focus of the accreditation process on operational systems critical to the safety and quality of patient care. "Shared Visions" represents a vision that the Joint Commission has with health care organizations--as well as with health care oversight bodies and the public--to bridge what has been called a gap or chasm between the current state of health care and the potential for safer, higher quality care. "New Pathways" represents a new set of approaches or "pathways" through the accreditation process that will support fulfillment of the Shared Visions.

2. When and how did the survey process change?

Beginning January 1, 2004, the new survey process has a greater focus on evaluating actual care processes by tracing patients through the care, treatment and/or services they received. In addition to conducting patient tracers, surveyors conduct "systems tracers" to analyze key operational systems that directly impact the quality and safety of patient care. There are a number of components of Shared Visions-New Pathways that contribute to the redesigned survey process, including:

  • A Priority Focus Process that enhances consistency and specificity in the on-site survey process.  This is done by compiling and using pre-survey information to focus the on-site survey. (See Priority Focus Process Q&A.)
  • Validation of the successful implementation of Plan(s) of Action, and/or assessment of measures of success, emanating from the mid-cycle Periodic Performance Review (PPR) in which standards compliance is assessed and opportunity for education on compliance issues is provided. The PPR was rolled out for ambulatory care, behavioral health care, home care, hospitals and long term care organizations in 2004. (See Periodic Performance Review Q&A.)
  • Tracer methodology to guide the on-site evaluation. This methodology follows or "traces" a number of patients, residents or clients through the organization's care process. These "tracers" are used to assess both an organization's compliance with selected standards and the organization's systems of providing care and services. (See Tracer Methodology Q&A.)
  • Better engagement of physicians in the accreditation process.
  • Elimination of the documentation review and performance improvement "storyboard" sessions.

3.  What does the new survey agenda look like?

The new survey agenda includes:

  • Opening conference.
  • Leadership interview.
  • Validation of organization's implementation and monitoring of the Plan(s) of Action emanating from the PPR.
  • Visits to care and service areas guided by the Priority Focus Process using the tracer methodology.
  • Environment of care review.
  • Human resources review.
  • Credentials review.
  • System tracers, that is, specific time slots devoted to in-depth discussion and education regarding the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, and/or other current topics of interest to the organization.
  • Closing conference.

4. What is the periodic performance review?

The periodic performance review (PPR) is a new form of evaluation that is conducted by the organization and focuses on patient safety and quality of care issues. The organization self-evaluates its compliance with all Accreditation Participation Requirements, standards and Elements of Performance (scoreable requirements) that are applicable to the services that the organization provides, and develops a Plan of Action for all areas of performance identified as needing improvement.  The Joint Commission will work with the organization to refine its Plan of Action to assure that its corrective efforts are on target. The organization will also identify Measures of Success (MOS) for validating resolution of the identified problem areas.

5. Is there an option to conducting the PPR?

Yes; in response to concerns about legal disclosure of PPR information shared with the Joint Commission, three options to the full PPR are available to organizations. The options and their requirements are:

Option 1

  • The organization performs the full self-assessment, develops the Plan of Action and MOS, but does not submit PPR data to the Joint Commission.
  • The organization attests that it has completed the foregoing activities but has, for substantive reasons, been advised not to submit its self-assessment or Plan of Action to the Joint Commission.
  • The organization may discuss standards-related issues with Joint Commission staff without identifying its specific levels of standards compliance.
  • At the time of the complete on-site survey, the organization provides its MOS to the Joint Commission for assessment.

Option 2

  • The organization remains accountable for conducting a full self-assessment and developing Plans of Action and applicable MOS, but does not submit PPR data to the Joint Commission.
  • The organization undergoes an on-site survey. The survey will be approximately one-third the length of a typical full on-site survey and the organization will be charged a fee to cover survey costs.  The organization receives a report of the survey activities.
  • The organization develops a Plan of Action to address any areas of non-compliance found during the on-site survey.  The Joint Commission will work with the organization to refine its Plan of Action.

At the time of the complete on-site survey, the organization provides its MOS to the Joint Commission for assessment.

Option 3

  • The organization remains accountable for conducting a full self-assessment and developing Plans of Action and applicable MOS, but does not submit PPR data to the Joint Commission.
  • The organization undergoes an on-site survey, as in Option 2, but no written documentation or written report of the survey is provided to the organization.
  • Findings are conveyed orally.  This eliminates the availability of a survey report for possible discovery from the organization, and permits the organization, as in Option 1, to control the language and documentation of the assessment activity.
  • At the subsequent full survey, surveyors do not receive any information relating to the organization's Option 3 survey findings.

6. What is the Priority Focus Process?

The priority focus process (PFP) is a data-driven tool that helps focus survey activity on issues most relevant to patient safety and quality of care at the specific health care organization being surveyed.

7. How does the PFP fit into the new accreditation process?

The PFP uses automation to gather pre-survey data from multiple sources including the Joint Commission, the health care organization and other public sources.  The PFP then applies rules to

1) identify areas of priority focus, and 2) guide the selection of patient tracers.  (As part of the priority focus process, surveyors will track patients, residents or clients through their experience of care within an organization, assessing the quality and safety of care provided.)  The PFP does not imply that priority areas are out of compliance or deficient in any way, rather, it lends consistency to the surveyor's on-site sampling process.

8. What is the tracer methodology?

Tracer methodology is an evaluation method in which surveyors select a patient, resident or client and use that individual's record as a roadmap to move through an organization to assess and evaluate the organization's compliance with selected standards and the organization's systems of providing care and services.

9. How do surveyors use tracers to assess care and safety?

Surveyors retrace the specific care processes that an individual experienced by observing and talking to staff in areas that the individual received care.  As surveyors follow the course of a patient's/resident's/client's treatment, they assess the health care organization's compliance with Joint Commission standards.  They conduct this compliance assessment as they review the organization's systems for delivering safe, quality health care.

10. How will individuals be selected as tracers?

Tracer patients, residents or clients will primarily be selected from an active patient list.  Typically, individuals selected for the tracer activity are those who have received multiple or complex services.

11. How many tracers will be completed at each organization?

The number of tracers completed depends on the length of the survey, however, the average three-day hospital survey with a team of three surveyors typically allows for completion of approximately 11 tracers.

12.  Are accreditation decisions the same?

No. Beginning in 2004, there are no scores, and accreditation decisions changed. Because of the emphasis on continuous compliance, Joint Commission eliminated the category of Accredited with Requirements for Improvement and instituted new rules for Conditional and Preliminary Denial of Accreditation decisions. As of January 2004, the new accreditation decision categories are: Accredited; Provisional Accreditation; Conditional Accreditation; Preliminary Denial of Accreditation; Denial of Accreditation; and Preliminary Accreditation (under the Early Survey Option).

Of the 6,000 accreditation decisions rendered annually, approximately 3 percent are referred to the Accreditation Committee for direct review and determination based upon meeting a decision rule for Preliminary Denial of Accreditation or Conditional Accreditation.  The Accreditation Committee, which meets every 6-8 weeks, determines whether organizations will receive one of these adverse accreditation decisions.  If the Accreditation Committee determines that an organization may be denied accreditation, the organization has the right to request a review of the decision before a decision to deny accreditation is rendered.

If an organization decides to request a review of Preliminary Denial of Accreditation decision, a hearing is scheduled before a Review Hearing Panel.  The Accreditation Committee will consider the panel’s report, and may decide to award Accreditation, Provisional Accreditation or Conditional Accreditation, or deny accreditation to the organization.

If the Accreditation Committee decides to deny accreditation, the organization may appeal to the Board Appeal Review Committee.  After review of the decision of the Accreditation Committee that considered the Review Hearing Panel’s report and the organization’s written submission to the Committee, the Board Appeal Review Committee issues the Joint Commission’s final accreditation decision.

13. Have performance reports changed?

Yes. In July 2004, Joint Commission began publishing new Quality Reports which are made available to the general public. The new reports use symbols--checks, pluses, minuses--to indicate organization performance and compare the organization to similar Joint Commission-accredited organizations both within the state and nationally. The reports highlight: organization performance related to compliance with Joint Commission's National Patient Safety Goals as applicable to the organization; awards and other recognition; and other information. For hospitals, the reports also show information related to National Quality Goals (ORYX core measures).  The Quality Reports are posted on  Quality Check™ on Joint Commission's website.

14. Does the Joint Commission require that hospital-based long term care units/facilities be included in the scope of the hospital’s survey?

No.  A hospital may elect to exclude its long term care component from the organization survey.  In this situation the accreditation award will note that the long term care facility is excluded from the accreditation.  Hospitals may also elect a Medicare/Medicaid certification-based accreditation option for its long term care unit/facility.  This option awards accreditation based upon an assessment of the 30 percent of long term care standards not addressed by the Medicare/Medicaid Conditions of Participation.  The accreditation certificate under this option would indicate that accreditation is substantially based on the organization’s most recent Medicare/Medicaid certification survey evaluation of its long term care services.

15. Why is the Joint Commission shifting from announced surveys to unannounced surveys?

The Joint Commission will be implementing unannounced surveys, effective January 2006:

  • To enhance the credibility of the accreditation process by ensuring that surveyors observe organization performance under normal circumstances;
  • To reduce the unnecessary costs that health care organizations incur to prepare for survey;
  • To address public concerns that the Joint Commission receive an accurate reflection of the quality and safety of care; and
  • To help health care organizations focus on providing safe, high quality care at all times, and not just when preparing for survey

In general, surveys will be performed with no notice to the organization.  However, special circumstances may necessitate that some organizations will be given short notice of an upcoming survey.  For example, security issues in correctional and Department of Defense facilities may require that a limited number of personnel at the facility receive short notice of the upcoming survey event.

16. How is the new survey process more consistently applied and be more organization-specific?

The Priority Focus Process (PFP) lends consistency to the surveyor's on-site sampling process by helping surveyors evaluate pre-survey data consistently for all health care organizations.  By using the PFP, the survey process also becomes more customized to the specific characteristics of the organization being accredited. In addition, by using the tracer methodology, surveyors will evaluate the services that a specific organization provides, as well as the interaction of departments and functions throughout the organization.

17. How have surveyors been retrained to effectively perform Shared Visions-New Pathways surveys?

At the January 2003 Annual Surveyor Conference, surveyors received education and testing in systems theory, organization behavior, and evaluation techniques under a program administered by the Kellogg School of Management at Northwestern University.  In addition, surveyors and their supervisors started receiving aggregated performance data in 2003. These internal management reports allow supervisors to track data by surveyor and in the aggregate. This creates another quality control mechanism and it also helps to identify areas for future surveyor development.

  • Annually, surveyors regularly receive the following training activities:
  • Annual all-surveyor training
  • Distance learning such as CDs, DVDs, web-based training, conference calls and study guides
  • Individualized study plans as needed
  • Field mentoring by their supervisor

Organizations that have significant concerns about the conduct of Joint Commission surveyors or the survey team are encouraged to immediately contact Joe Cappiello, Joint Commission’s Vice President of Accreditation Operations, at (630) 792-5757.

18. Why will the Joint Commission be instituting a subscription billing model in 2006?

Periodically throughout the past decade, accredited organizations have requested that the Joint Commission change its pricing structure to comport with billing approaches used by other accrediting bodies, which spread survey fees over the entire accreditation cycle.  Unfortunately, the accreditation process that the Joint Commission had in place during this period did not support such a change.  However, beginning in 2006 – after which regular accreditation surveys will be conducted on an unannounced basis – the use of an annual subscription billing approach for the payment of accreditation fees will become fully consistent with the substantially continuous nature of the new accreditation process.


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