The Joint Commission (TJC) is an independent, non-profit organization that evaluates and accredits healthcare organizations and programs across the United States. TJC assesses compliance with rigorous performance standards related to patient care and safety. Achieving accreditation from TJC signifies that a healthcare facility meets or exceeds a defined set of quality benchmarks. These evaluations are conducted through on-site surveys and assess organizational commitment to quality standards.
The Standard Triennial Survey Cycle
The core frequency for accreditation renewal for most healthcare organizations is a three-year cycle. This period means that a successful full survey grants the organization an accreditation status that generally lasts for 36 months. For an organization to maintain its accredited status, it must undergo a full on-site resurvey before the three-year period concludes.
This three-year period is the standard length for hospitals and many other accredited programs, though notable exceptions exist. Clinical laboratories, for instance, are assessed on a more frequent schedule, with a full on-site survey occurring every two years. The accreditation decision is based on an objective evaluation of compliance with performance standards and other requirements.
Compliance is scored according to specific performance expectations. Throughout the three-year term, accredited organizations are expected to maintain performance and continuous compliance, not just in preparation for the next visit. This expectation is supported by programs like Intracycle Monitoring, which helps organizations address areas of risk and prepare for their upcoming renewal survey.
Understanding the Unannounced Survey Window
While the accreditation period is three years, the survey itself is almost always unannounced for most accredited organizations. This element of surprise is intentionally designed to ensure that the healthcare organization maintains continuous compliance with safety and quality standards every day, rather than preparing only for an anticipated date. The unannounced nature allows surveyors to observe the organization under normal working conditions, providing a more accurate picture of ongoing operations.
The specific window for this unannounced triennial resurvey begins 18 months after the organization’s last full survey. This means that the survey can occur anytime between 18 and 36 months from the date of the previous visit. The organization is essentially “in the window” for a full 18-month period, during which surveyors may arrive without prior notification.
On the day of the visit, the organization is typically notified that a survey is scheduled by 7:30 a.m., but this is only confirmation of the arrival and not advance notice. There are a few exceptions to the unannounced policy, such as for Department of Defense facilities or certain small ambulatory or home care organizations, which may receive a short advance notice. However, the vast majority of hospital and Medicare-certified organizations receive an unannounced visit.
Survey Timing for Specific Events
Surveys are sometimes conducted outside of the standard triennial renewal cycle due to specific organizational events or compliance concerns.
Initial Surveys
For a new organization seeking its first accreditation, the initial survey is generally announced, allowing the facility to prepare for its first comprehensive review. These initial visits are essential for demonstrating that the organization can meet all applicable standards from the outset.
Follow-Up Surveys
Another type of non-routine visit is the follow-up survey, which is required when a full survey identifies significant deficiencies. If the organization’s response, called an Evidence of Standards Compliance, is not sufficient to fully resolve all Requirements for Improvement, an on-site visit is scheduled. These visits are typically limited in scope, focusing only on the areas of non-compliance to verify that sustained corrective actions have been implemented.
For-Cause Surveys
The most unexpected type of visit is the for-cause survey, which is triggered by external factors rather than the accreditation cycle. These unscheduled visits occur when TJC receives information about a serious compliance violation, a sentinel event, or a major patient safety concern. The information often comes from a complaint or report that suggests an immediate threat to the health or safety of the public or patients. The for-cause survey is highly focused and is conducted to investigate the specific issue that triggered the concern.