How to prepare for a Joint Commission survey
Accreditation is a cornerstone of patient safety and quality care. As a laboratory surveyor for Joint Commission, I have the privilege of working with laboratories across the country to support their quality improvement efforts. A common question I receive is how labs — whether in a small community hospital or part of a large health system — can best prepare for their Joint Commission accreditation survey. This question is even more pressing in today’s healthcare landscape, where staffing and resources are often limited.
Turn daily tasks into survey prep
The best piece of advice I like to give to my peers is simple: make survey readiness a daily habit. For example, instead of just signing and dating a document and then filing it away, take the opportunity to review its completeness and accuracy. By closely reviewing documents, one can begin to identify trends and take immediate corrective action if needed.
A good approach is to take a critical value from the daily critical value list and locate all necessary documentation in a patient’s medical record. If time allows, review proficiency testing documentation related to the critical value, continue with quality control, temperature monitoring records, etc. Such daily tasks can help labs stay prepared without feeling overwhelmed.
Use the survey guide
Another simple but important step is to review Joint Commission’s survey guide, which includes a document list. These are the documents that the surveyor will request during the survey. Work as a team to collect these documents early. And as they are gathered, ask, “Does this reflect our current practice?” This proactive review helps identify and address any gaps before survey.
Three key focus areas
There are three common areas that labs struggle with: proficiency testing, employee competency, and documenting procedures. These areas have been consistent for the past several years. By focusing on these areas, labs can address potential roadblocks before they arise.
Proficiency testing
In the laboratory world, proficiency testing is like midterms and finals. This is when a Centers for Medicare & Medicaid Services (CMS)–approved provider sends an unknown specimen to a lab for analysis two to three times a year. The results are then compared to expected values or consensus results.
Unacceptable results are becoming more common, and repeated failures can put a lab at risk of losing testing capability. Joint Commission surveyors review two years or six events of proficiency testing. We do not just want to see pending results; we also want to see completed ones. For labs that use the College of American Pathologists (CAP) proficiency programs, providing a scorecard for the past six events is more efficient than flipping through multiple binders.
Given the myriad of reasons for failing proficiency testing — clerical, technical, or random errors — I always encourage labs to conduct a thorough investigation every time a result comes back as unacceptable. Performing a root cause analysis can help identify the underlying issue and prevent recurrence. While Joint Commission does not require this step, labs that do it often take proactive corrective actions that ultimately improve performance.
Employee competency
Training and competency are two separate things but are often mistaken as the same. Training is how to do things the organization’s way, while competency is demonstrating the ability to perform tasks correctly.
I often share this analogy: when I was 16 years old, my brother trained me how to drive a stick shift. Years later, I still have not shown him competency.
Joint Commission requires initial training and initial competency to be documented separately. This is unique to Joint Commission and is not required by other accreditors or CMS. Using the same document for both is a common mistake.
During the survey, we check that competency requirements are met and review human resources (HR) files for employees included in tracers. In small labs (5-6 staff), we likely will review almost all files; in larger labs, we will choose select files. Additionally, we verify that job descriptions meet minimum requirements for education, experience, certification and credentials.
Surveyors do not interpret documentation; we ask labs to show and explain their process. We also check compliance with the Clinical Laboratory Improvement Amendments (CLIA) six procedures of a competency assessment:
- Directly observing routine test performance, including patient preparation and, if applicable, specimen handling, processing, and testing
- Monitoring the recording and reporting of test results
- Reviewing intermediate test results or worksheets, quality control (QC) records, proficiency testing (PT) results, and preventive maintenance records
- Directly observing instrument performance, maintenance, and function checks
- Assessing test performance using previously analyzed test specimens, internal blind testing samples, or external PT samples
- Assessing problem-solving skills
Documenting procedures
Every laboratory process should have a documented procedure — and actual practice must match that procedure. I often find mismatches: a procedure exists but is not followed, or a practice exists without a procedure. Both need to align.
Best practices for documenting procedures are as follows:
- Review and update procedures annually.
- Involve staff in updates to ensure accuracy.
- Maintain version control and store documents in a centralized system for easy access.
Engage team through mock tracers
The best way to prepare for a Joint Commission survey is to make sure all team members participate and feel part of the accreditation process. Mock tracers are an excellent tool for this. Simulate the entire process — from opening conference to exit conference — and involve other departments like respiratory, nursing, and quality. This builds collaboration and reinforces the shared goal of patient safety and quality care for all.
Survey readiness is not a one-time event — it is a daily habit. Start small today: review one document, verify one competency, or begin to map out a mock tracer. Joint Commission is always here to help labs on their accreditation journey. For helpful resources, visit www.jointcommission.org.
About the Author
Harriet Briggs, MBA, MLS(ASCP)
is a Field Director – Laboratory Surveyor Program at Joint Commission. In this role, she is responsible for the management and oversight of field staff who conduct laboratory accreditation surveys. Prior to her role as Field Director, Briggs was a laboratory surveyor.