The Joint Commission (TJC) revamped their final accreditation survey report format for all accreditation surveys and certification reviews conducted after January 1, 2018. Working with customers, and field and central office staff, TJC addressed clients’ requests to have a user-friendly version of the reports to help prioritize their organizations’ most significant findings. Additionally, an Excel version of the report will appear in the organizations’ secure website (Joint Commission Connect) after the report is finalized to enable the organization to easily customize the report to develop and share action plans with their staff.

The main components of the original report still exist; however, they are rearranged a little differently, and there are several new features which appear promising.

Cover page

The cover page had essentially no changes from the previous report.

Table of Contents

This is new and a welcome feature, which includes hyperlinks to the main sections of the report.

Executive Summary

Previously, the executive summary was written as a narrative. Information is now displayed in tabular format as a quick reference identifying the program surveyed (e.g., hospital), the survey dates, the event outcome (e.g., RFI), follow-up activity (e.g., clarification/evidence of standards compliance), and follow-up timeframes or submission due date (e.g., 10 days/60 days).

What’s Next: Follow-Up Activity

The next few pages of the report contain a table listing the standard/element of performance (EP), its placement on the SAFER matrix, the corresponding Centers for Medicare and Medicaid Services (CMS) Condition of Participation section number from the Federal Register, and the tag number. The last column contains checkmarks to indicate if the citation requires an Evidence of Standards Compliance (ESC) plan, and that it is due within 60 calendar days.

SAFER Matrix

The SAFER matrix was introduced last year and has been well-received by clients. At a glance, leaders can visualize which standards/EPs were most challenging for their organization by color and placement.

CMS Summary

This section is included only if the survey was conducted to satisfy CMS deeming requirements. It includes a crosswalk of the CoPs that were cited, their score (standard, Condition-level, or Immediate Jeopardy), and the corresponding TJC standards/EPs.

Requirements for Improvement

This section provides a fresh approach to reporting the surveyors’ observations. Using a seven-column table, the standards are listed alphabetically, followed by the EP number, the SAFER placement, the EP text (note that the standard text is not cited here), the observation(s), and, if applicable, the corresponding CoP and its score. For example, if scored as “IC.02.02.01,” with “EP 1” noted, only the text for the applicable EP (EP 1) will be included in the table. The main report table will still include the EP and the corresponding EP text, which will correlate with the observation and other components.

This new formatting style presents results of the hospital survey in a more succinct way, for a quick digestion of results for leadership. Accreditation facilitators will appreciate having this section in Excel, as they can download the report internally, and then customize it to create action plans for their organizations.

Appendix

The last section contains the detailed text of the CoPs and TJC standards and EPs.

These appendices act as reliable references for clients who would like more detail on each standard that was cited in the hospital report.


If you would like more information on this new reporting structure and how it may impact your organization, email Victoria Fennel, PhD, RN-BC, CPHQ, Director of Accreditation and Clinical Compliance or contact the office.

Additionally, read about how Compass can help support your organization with CMS and TJC mock surveys.

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