Online Extras for the Joint Commission International Accreditation Hospital Survey Process Guide, 4th Edition

Tools Hospitals Can Use to Prepare for the On-Site Survey

Hospital leaders and staff should prepare for the on-site survey by Joint Commission International (JCI) surveyors before the surveyors arrive. They can accomplish this using a variety of means, including conducting risk assessments, ensuring they fill out documents that will be reviewed by the surveyors, and assessing their compliance with JCI standards. The following tools will help hospitals more efficiently and accurately prepare for JCI on-site surveys, whether initial surveys or re-surveys. All the tools are in Word format, so hospitals can fill them out electronically or customize them.

Medical Staff Qualifications Worksheet
During the Staff Qualifications and Education Session, JCI surveyors will interview hospital staff to document the hospital’s processes for recruiting, orienting, educating, and evaluating all hospital staff. In addition, the hospital’s compliance with Staff Qualifications and Education (SQE) standards will be evaluated. Hospital staff can use the Medical Staff Qualifications Worksheet provided here as a checklist to monitor compliance with SQE standards.

Nursing Staff Competency Assessment Process Review Form
Other Health Care Professional Staff Competency Assessment Process Review Form
During the Staff Qualifications and Education Session, JCI surveyors will interview hospital staff to addresses the hospital’s processes for evaluating the credentials of the medical, nursing, and other health care professional staff and their ability to provide clinical services consistent with their qualifications. The hospital can review all personnel and credential files using the two Competency Assessment Process Review Forms provided here to ensure that all required elements are in the files.

Law and Regulation Worksheet
Some of the standards surveyed by JCI reference laws and/or regulations that are specific to the country in which the hospital provides care, treatment, and services. The Law and Regulation Worksheet provided here is a checklist hospitals can use to identify particular standards that can potentially be affected by country-specific laws and regulations. The worksheet also allows hospitals to name the law and/or regulation, to provide a summary of the law and/or regulation, to indicate whether the law and/or regulation is more stringent than the JCI standard, and to list other regulatory agencies that inspect or survey for the law and/or regulation.

External Auditing Body Recommendation Worksheet
In addition to JCI, hospitals undergo surveys by government agencies, regulatory bodies, accrediting organizations, and other invited evaluators. Hospitals can use the External Auditing Body Recommendation Worksheet provided here to compile information regarding the results of these on-site evaluations, and this worksheet should be provided to the JCI survey team at the document review session.

Compliance Assessment Checklist: Governance, Leadership, and Direction (GLD)
Compliance Assessment Checklist: Medication Management and Use (MMU)
Hospitals should assess their compliance with JCI standards before their scheduled on-site survey. There are numerous ways for hospitals to accomplish this, including conducting mock surveys, interviewing staff, reviewing physical facilities, and performing self-assessments. The Compliance Assessment Checklists provided here are examples of checklists hospitals can use to evaluate compliance with standards and Measurable Elements from two of the chapters in the hospital standards manual.