Sample Generic Survey Agenda

About four months before an accreditation survey, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, sends a survey-planning questionnaire to the hospital so a customized survey agenda can be developed. The Joint Commission also provides other materials to help the organization identify staff who’ll be involved in the on-site survey and documents that should be available to the surveyors.

Using a generic agenda like the one below, the Joint Commission works with the hospital to develop a final agenda that will be used for the accreditation survey. When a consulting company is enlisted to perform a mock survey for an organization, the hospital is typically asked to use such a generic agenda to highlight where help is needed most.

In most instances, the Joint Commission survey team is composed of an administrator, nurse, and physician. In smaller hospitals, the survey team includes two surveyors, usually a nurse and a physician.

DAY ONE

All Surveyors

• 8:30-8:45 am: Opening Conference

• 8:45-9:15 am: Performance Improvement Overview Presentation

• 9:15-11:00 am: Document Review Session

• 11:00-11:45 am: Leadership Interview

• 11:45-12:15 pm: Lunch

Physician Surveyor

• 12:30-2:00 pm: Patient Care Setting Visit

Includes inpatient units and other sites where care is provided, including ambulatory settings and anesthetizing locations

• 2:00-3:00 pm: Anesthetizing Location Visit

Includes inpatient units and other sites where care is provided, including ambulatory settings and anesthetizing locations.

• 3:00-4:00 pm: Emergency Services Visit

Nurse Surveyor

• 12:30-2:00 pm: Patient Care Setting Visit

• 2:00-3:00 pm: Anesthetizing Location Visit

• 3:00-4:00 pm: Patient Care Setting Visit

Administrator Surveyor

• 12:30-1:15 pm: Rehabilitation Services Visit

• 1:15-4:00 pm: Building Tour

Includes visits to admitting, kitchen, resource center, storage, central supply, and laundry (if applicable).

All Surveyors

• 4:00-4:30 pm: Survey Team Meeting

DAY TWO

All Surveyors

• 8:15-8:45 am: Daily Briefing

Physician Surveyor

• 8:45-9:45 am: Pathology and Clinical Laboratory Services Visit

Includes survey of blood and blood components.

• 9:45-10:45 am: Medical Staff Credentials Interview

• 10:45-11:45 am: Medical Staff Leadership Interview

• 11:45 am-12:45 pm: Lunch: Medical Staff Conference (Optional)

Nurse Surveyor

• 8:45-10:00 am: Patient Care Setting Visit

• 10:00-10:45 am: Anesthetizing Location Visit

• 10:45-11:30 am: Infection Control Interview

• 11:30 am-12:15 pm: Nursing Leadership Interview

Administrator Surveyor

• 8:45-9:30 am: Patient Care Setting Visit

• 9:30-10:15 am: Hospital Department Directors Interview

• 10:15 am-12:15 pm: Review of Environment of Care Documents

Nurse and Administrator Surveyors

• 12:15-12:45 pm: Lunch

Administrator Surveyor

• 1:00-1:45 pm: Chief Executive Officer/Strategic Planning and Resource Allocation Interview

Includes Ethics Interview issues.

• 1:45-2:15 pm: Pharmacy Services Visit

Physician and Nurse Surveyors

• 1:00-2:00 pm: Medical Record Interview

Physician Surveyor

• 2:00-2:45 pm: Patient Care Setting Visit

• 2:45-4:00 pm: Imaging Services Interview

Nurse and Administrator Surveyors

• 3:00-4:00 pm: Human Resources Interview

All Surveyors

• 4:00-4:30 pm: Survey Team Meeting

DAY THREE

All Surveyors

• 8:15-8:45 am: Daily Briefing

• 8:45-9:45 am: Patient Care Interview

Physician Surveyor

• 9:45-10:30 am: Performance Improvement Team Interview

Nurse Surveyor

• 9:45-10:30 am: Performance Improvement Team Interview

Administrator Surveyor

• 10:00-11:00 am: Information Management Interview

All Surveyors

• 10:30-11:30 pm: Performance Improvement Coordinating Group Interview

• 11:30-12:00 pm: Lunch

• 12:00-3:00 pm: Team Meeting to Integrate Survey Findings

• 3:15-4:15 pm: Leadership Exit Conference