Joint Commission International

Survey Process Guide

for Hospitals
Including Academic Medical Center Hospitals

7th Edition | Effective 1 January 2021

Joint Commission International Mission
A division of Joint Commission Resources, Inc.
The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the
international community through the provision of education, publications, consultation, and evaluation
services.

© 2020 The Joint Commission, on behalf of Joint Commission International

Published by Joint Commission Resources

Oak Brook, Illinois 60523 USA
https://www.jcrinc.com

Joint Commission Resources educational programs and publications support, but are separate from, the
accreditation activities of Joint Commission International. Attendees at Joint Commission Resources
educational programs and purchasers of Joint Commission Resources publications receive no special
consideration or treatment in, or confidential information about, the accreditation process.

All rights reserved. No part of this publication may be reproduced in any form or by any means without
written permission from the publisher. Requests for permission to make copies of any part of this work should
be sent to permissions@jcrinc.com.

ISBN: 978-1-63585-150-2

For more information about Joint Commission International, please visit

https://www.jointcommissioninternational.org/.

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 Contents

Contact Joint Commission International....................................................................v

Joint Commission International Surveys: General Information
Which Hospitals Are Eligible for a JCI Accreditation Survey?............................... 2
How to Request a JCI Accreditation Survey.......................................................... 4
Survey Scheduling, Postponements, and Cancellations.......................................... 6
Tools for Accreditation Preparation, Including the Standards Manual................... 7
Scoring Guidelines.............................................................................................. 11
Accreditation Decision Rules............................................................................... 17
Accreditation Preparation.................................................................................... 20
Tool: Accreditation Preparation Time Line.................................................... 22
The On-Site Survey............................................................................................. 25
Sample Hospital Survey Agenda.......................................................................... 26
Sample Academic Medical Center Hospital Survey Agenda................................. 30
Tracer Methodology............................................................................................ 35
The Accreditation Decision................................................................................. 40
Survey Agenda: Detailed Descriptions
Opening Conference and Agenda Review........................................................... 42
Orientation to the Hospital’s Services.................................................................. 44
Document Review............................................................................................... 46
Daily Briefing...................................................................................................... 50
Leadership for Quality, Patient Safety, Ethics, and Culture of Safety Interview.... 52
Quality Program Interviews: Clinical.................................................................. 56
Quality Program Interviews: Operations............................................................. 58
Department/Service Quality Measurement Tracer............................................... 61
Tool: Clinical/Hospital Operations Measures Tool......................................... 64
Supply Chain Management and Evidence-Based Purchasing Interview and Tracer.... 65
Individual Patient Tracer Activity........................................................................ 67
Organ and Tissue Transplant Services Interview and Tracer................................. 70
Patient Interview Session..................................................................................... 72

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 FMS Document Review and Facility Tour........................................................... 73
Department/Service-Specific Tracers.................................................................... 77
Hemodialysis Tracer....................................................................................... 77
Laboratory Tracer.......................................................................................... 78
Laser Safety Tracer......................................................................................... 79
Radiology and Diagnostic Imaging Tracer...................................................... 80
Transfer and Medical Transport Tracer........................................................... 81
Information Management and Technology Tracer.......................................... 82
System Tracer: Facility Management and Safety................................................... 85
System Tracer: Medication Management and Medication Supply Chain............. 88
System Tracer: Infection Prevention and Control................................................ 91
Undetermined Survey Activities.......................................................................... 95
Medical, Nursing, and Other Staff Education Qualifications Sessions................. 96
Tool: Medical Staff Qualifications Worksheet................................................ 98
Tool: Nursing Staff Qualifications Worksheet.............................................. 101
Tool: Other Professional Staff Qualifications Worksheet.............................. 103
Tool: Medical Student and Trainee Qualifications Worksheet...................... 105
Closed Patient Medical Record Review............................................................. 106
Tool: Closed Patient Medical Record Review Form..................................... 107
Surveyor Team Meetings................................................................................... 125
Surveyor Report Preparation............................................................................. 126
Leadership Exit Conference............................................................................... 127
Additional Sessions for Academic Medical Center Hospitals: Detailed Descriptions
Medical Professional Education Leadership Interview....................................... 129
Medical Student and Trainee Interview............................................................. 131
Tool: MPE Supervision Medical Record Documentation............................. 133
Human Subjects Research: Leadership and Process Interview............................ 135
Survey Planning Tools
External Auditing Body Recommendation Worksheet....................................... 139
Required Documents........................................................................................ 140
Standards That Reference Laws and Regulations................................................ 154
Tool: Laws and Regulations Worksheet........................................................ 155

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