Joint Commission Surveys, Part 3 - Self-Survey

By Matt Swanson, Director of Operations, BS, MLS(ASCP), CLSSBB

December 04, 2020

This article, “Self-Survey”, is the third in a four-part series on preparedness for a Joint Commission Survey. This article addresses the process of performing a mock Survey on your own department or facility. Stay tuned to StaffReady’s blog for the final installment.

No Fear

As we mentioned in the last article, it is time to become skeptical, hard-nosed, and thick-skinned.

You and your fellow leaders are armed with the Joint Commission Standards, previous Survey findings, Plans of Correction and Evidence of Compliance. You know where to start.  

It is now time to turn your attention to your own facility or department, and view it as if you had never seen it before. Observe with a critical eye.

No Fear – but sometimes the truth hurts.

Overview: Walking Around

When viewing your department or facility as an “outsider”, take the same path as a Surveyor would. If you usually come in through the employee entrance, come in through the front door. First impressions mean a lot. Is the lobby clean, organized, and well lit? Is the signage clear? Would a Surveyor know how to find each department? Even in a small facility, this may not be obvious to the individual who is naive to your location.

As you walk, take in your surroundings. A fire extinguisher – what’s the inspection or fill date? Does that stain on the ceiling look like a water leak? Would that bit of frayed carpet be considered a tripping hazard? These might be fairly minor issues, but can create a bad impression.

As you approach the outpatient registration area, is there any PHI exposed? Are registration conversations given at least a modicum of privacy? Are orders and other paper records kept out of view? The temptation with any observations you make is to make excuses:

Be careful with that last excuse. Joint Commission standards are standards of excellence. They are the standards your organization aspires to and needs to meet for accreditation. Excusing a solution away as “too expensive” is lazy. Look at problems with fresh eyes. More on Teamwork later.


The Joint Commission (TJC) has used the Tracer Methodology as a means of assessing compliance and outcomes since 2004. One example Tracer activity might go as follows:

Each of those requests, once fulfilled, can easily lead to other questions. The Survey team can quickly gain a sense of the safety and consistency of care across departmental lines within your organization. So – time to do your own Tracers.

Select patient records coming from your department (adhering to all your organization’s rules regrading access to patient records, of course). Look at every touch point that leads to that record on that patient on that day – perhaps specimen collection, quality control, temperature and humidity records, competency assessments on staff, quality assurance activities, and more. The records should all be retrievable and displayable to a Surveyor.

If you cannot produce these sorts of records or are missing some vital steps in the process of operating your department, prepare for deficiencies on Survey day! You may have time, however, to recover “lost” records – stored in the wrong folder in the document imaging system, in a binder filed in the wrong location, or even records in the basement that were moved by housekeeping. In the worst case – records that are irretrievably lost – document this using your organization’s quality assurance process. Self-discovery of an issue (and the steps taken to prevent its recurrence) are far better than a surprise on Survey day.


By far the best practice is to carry out Mock Surveys within your organization. If you are a part of a larger healthcare system, organizing teams from one facility to survey your facility are particularly effective. There are numerous online resources for such an undertaking. TJC has excellent content on their websites.1, 2, 3

Remember, it’s time to thicken your skin.

I have been humbled by this process; apparently my “perfect” department left a bit to be desired in a couple of areas. Once the bruises to my ego healed, we were able to improve and standardize processes between facilities. We uncovered areas that needed attention, and developed internal best practices from other areas. All in all, we improved our departments, and created a better environment for success and patient care.

A Mock Survey is quite an undertaking, involving representatives from every department and service line in your organization. It is usually sponsored by your Quality Management or Accreditation and Regulatory Compliance, or similar team. It takes a substantial amount of planning, and should be treated as seriously as an actual Survey. A closing conference should be held, and leadership attendance should be mandatory.

Ready for the Last Steps

You and your organization have done quite a bit of work to get to this point. You have validated processes in your departments, uncovered and corrected problems. Hopefully, you have learned from one another to improve the quality of care in your institution. Our last article in this series, “Have a Plan”, speaks to keys points to remember when Survey Day arrives.

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Interested in learning more about 2021 Joint Commission Surveys? Join us as we sponsor a Joint Commission webinar entitled “Your Joint Commission survey during the COVID-19 Pandemic: What has changed?” on January 13, 2021, 10:00 am PST, 1:00 EST. Click here to register.




Photo Credits: rawpixel and hilch

Matt Swanson, Director of Operations, BS, MLS(ASCP), CLSSBB

Matt Swanson is the Director of Operations at StaffReady. He came to StaffReady with 29 years of experience in the clinical laboratory, with roles varying from Bench Tech to Operations Management to Consultant to Business Intelligence Analyst.  He became a Certified Lean Six-Sigma Black Belt in 2017. Find Matt on LinkedIn.