[Clinic name]
Controlled document
[Address]
[Registration or licence number]
Joint Commission survey checklist
1The survey document list
- Performance and quality improvement data from the past 12 months.
- Infection control plan and 12 months of surveillance data.
- Organisation chart, list of sites and locations, and list of contracted services.
- Appointment or surgery schedules for each day of the survey.
- Your most recent culture of safety and quality evaluation.
2The record of care
- Notes signed and complete for every visit in the last month.
- Two identifiers used on every record, label and specimen.
- A medication list taken at the start of the episode and given to the patient at the end.
- Diagnostic tests followed from the order to the patient, with a named owner.
3National Patient Safety Goals
- Medication labelling in procedural settings, checked on a live procedure.
- Anticoagulation monitoring, if you prescribe it.
- Hand hygiene monitored against CDC or WHO guidance.
- A named leader and an action plan for health outcomes for all.
- Preprocedure verification, site marking and time-out for every invasive procedure.
4People
- Credentials files with current licences, training and privileges granted by the governing body.
- Competency assessment and orientation records for staff and contracted staff.
- A named account for every person in every clinical system.
5After the survey
- Read the final Summary of Survey Findings on Joint Commission Connect.
- Submit Evidence of Standards Compliance within 60 days for each finding that needs it.
- Show leadership involvement and a preventive analysis for higher-risk findings.
6What a Joint Commission surveyor may ask
- Walk me through this patient's care, from the day they first contacted you. What to show, the record from first contact to the end of the episode, with hand-offs.
- How do you make sure an abnormal test result is followed up? What to show, the tracking method and the follow-up for a real patient.
- Which two identifiers do you use, and where? What to show, the identifiers on the record, the letter and the label.
- What medicines was this patient taking, and what did they leave with? What to show, the medication list, the comparison and the written information given.
- How do you protect the confidentiality of the health information you collect? What to show, access controls, named accounts and how access is checked.
- How do you use data to improve performance? What to show, a measure, its trend and the project it drove.
- Who granted this clinician's privileges, and when were they last reappraised? What to show, the credentials file and the governing body's decision.
AAppendix, Readiness checklist row
- A.1Chapter or goal ______
- A.2What we checked ______
- A.3Where the evidence lives ______
- A.4Owner ______ Date checked ______
- A.5Gap, likelihood of harm and scope ______
- A.6Corrective action and completion date ______