Here is a timeline for how the Joint Commission on Accreditation of Healthcare Organizations will implement its new survey process:
• Organizations at the midpoint in their accreditation cycle as of January 2004 and beyond (due for survey in or after July 2005) will receive a self-assessment tool in July 2003. Facilities will have three to six months to complete the assessment and to plan corrective actions for any deficiencies. Although organizations scheduled for survey before July 2005 won’t be required to submit the self-assessment, they will receive the self-assessment tool to help them prepare and become familiar with the revised standards.
• An accredited organization will complete the self-assessment at the 18-month point in its three-year accreditation cycle, and it will rate its level of compliance with all standards applicable to that organization. There will be no on-site surveyor visit at the 18-month point.
• In the self-assessment, if an organization finds itself not compliant in any standards area, it must detail the corrective actions that it has taken or will take to comply.
• A Joint Commission staff member will follow up with the organization to review its findings, approve the corrective actions, and provide advice or assistance on those actions.
• At the 36-month point, surveyors will go on site to verify that the organization has implemented the corrective actions as laid out in its self-assessment. The survey also will include a validation of the self-assessment based on review of specific critical areas.