How to get survey questions answered by The Joint Commission

Consider the following scenario: A health care organization is within its survey window and staff has questions about how The Joint Commission will evaluate compliance on a specific environment of care or life safety code issue.

Solution? Contact The Joint Commission via one of its many available resources to clarify any confusion about survey compliance and the accreditation process. Organizations can reach out before, during or post-survey. Available options include: 

Request a phone call from a Joint Commission physical environment specialist.

• Health care organizations can always request a phone call with a Joint Commission physical environment specialist to clarify a survey-related issue. 
• Organizations need to provide specific availability for a return call when requesting a phone call. Upon receipt of a request, a member of The Joint Commission’s Physical Environment department will return the call within the specified timeframe. Joint Commission representatives will make up to two call-back attempts per request.

Call your Joint Commission account executive.

• All Joint Commission-accredited organizations are assigned a dedicated account executive who can communicate with health care organization staff members regarding survey compliance concerns. Those who do not know who their account executive is can call 630-792-3007.
• All relevant information, including the specific standard or element of performance in question, along with descriptions of currently employed processes to meet the survey requirements should be gathered prior to contacting the account executive. Written policy, which cannot be directly authored or reviewed outside of a survey event, should not be included. The Joint Commission can then conclude if an organization is in alignment with the stated requirements. Consider that non-specific inquiries are more difficult to address since most code-based guidelines are subject to literal interpretation.

Contact The Joint Commission’s Standards Interpretation Group to answer general standards questions.

• During survey, The Joint Commission Standards Interpretation Group (SIG) can be contacted online or at 630-792-3007 if interpretation of a standard is necessary. Organizations should inform the life safety code surveyor of the request who will then relay the information to the on-call physical environment specialist. Expect the physical environment specialist to require time to research specific code requirements associated with the question. Then, a meeting time will be scheduled for the caller, the life safety code surveyor and a member of Joint Commission’s SIG to address the question(s).

Submit general questions via The Joint Commission’s website.

• Questions can be submitted through The Joint Commission’s website, which provides shareable responses for hospital staff, shortly after a request is made.

The Joint Commission is here to support its accredited health care organizations with standards-related questions and in navigating accreditation requirements through a variety of options, whether before, during or after a survey. 

Herman McKenzie is director of The Joint Commission Standards Interpretation Group (SIG) Physical Environment.