Excellence. Recognition. Trust.
At the heart of The Joint Commission (TJC) accreditation is one overall goal: “to continuously improve healthcare.” Hospitals, nursing homes, and other healthcare centers share this goal and strive for it every day. TJC’s standards, guides, and training options help facilities reach that ever-advancing goal.
TJC’s prestigious accreditation and highly respected certifications testify a facility’s dedication to excellence and may be required for licensing and payments from both Medicaid and Medicare. This recognition also provides peace of mind to patients and their families, knowing that they are in the hands of a reputable and trustworthy facility.
This article will help you with Joint Commission preparation and accreditation.
What is the Joint Commission?
The Joint Commission is an independent, not-for-profit accrediting institution for healthcare organizations. TJC is the nation's oldest and largest standards-setting and accrediting body in healthcare. To earn and keep the Gold Seal of Approval, an organization prepares for and undergoes an on-site survey by a Joint Commission survey team at least once every three years.
In the words of Dr. Jonathan B. Person, President and CEO of TJC: “We aim to be an ally to every provider, equipping them with state-of-the-art quality standards and unparalleled resources aligned to their improvement journey.”
How to prepare successfully for the Joint Commission survey
To get a good start on Joint Commission prep, learn more about the accreditation process and its benefits for your organization. At your request, TJC can provide a 90-day free trial access to its online accreditation standards manual and e-Alerts for important updates.
Make sure to have the updated information.
As of July 1, 2025, the Joint Commission simplified the accreditation process, and more streamlining is announced for 2026. The standards have been slashed from 1,551 to 774, consolidating some and eliminating others. Major changes have occurred in several areas, including infection prevention standards and emergency management.
Then, follow these general steps.
Pre-survey review and self-assessment
- Review the requirements: Find TJC accreditation requirements in the manual specific to your setting (available for purchase from the Joint Commission Resources).
- Assess your Joint Commission readiness: Compare your organization's current practices with TJC standards and survey requirements.
- Identify gaps: Determine which areas need improvement to meet the standards.
- Formulate an action plan: Create a practical plan with a timeline for compliance with all the standards by the time of the on-site Joint Commission survey.
- Review process and methodology: Familiarize yourself with TJC’s tracer survey process and Survey Analysis for Evaluating Risk (SAFER™) scoring methodology.
Application and documentation
- Submit application and fee: Along with your application for accreditation, you must remit a fee. The fee varies according to the organization's type, size, and complexity.
- Indicate a “ready” date: The application allows you to indicate a realistic date within the next 12 months for the on-site Joint Commission inspection and survey. This date indicates when you will be ready, not the specific date of the survey.
- Compile all necessary documents: This includes policies, procedures, and evidence of compliance with standards.
On-site survey
- Preparation: Plan how you will present your program in the opening conference, and appoint those who will accompany the surveyors sent by the Joint Commission. Have all the documentation organized.
- Survey procedure: Surveyors have their own Joint Commission visit schedule and evaluate compliance with standards by conducting interviews, observing procedures and practices, and examining documents.
- Feedback: During the on-site Joint Commission visit, you will receive feedback and recommendations. At the end of the survey, you will have access to your preliminary “Summary of Survey Findings Report,” which will include any Requests for Improvement (RFIs).
Post-survey follow-up: Findings and recommendations
- Complete all post-survey follow-up activities: Implement requirements or corrective actions based on the survey findings and recommendations.
- Submit your Evidence of Standards Compliance report: Within the stipulated time, often 45 to 60 days, provide evidence of the corrections or improvements made to address any RFIs.
Accreditation
- Review process: The Joint Commission reaches a conclusion typically within two weeks to one month after the submission of the Evidence of Standards Compliance report.
- Decision and notification: TJC sends written notification of the decision, confirming whether the organization has earned TJC’s Gold Seal of Approval, other accreditation status, or denial. Denial is very rare and is subject to review and appeal by the organization.
When you receive the Gold Seal of Approval or accreditation, let everyone know and celebrate the achievement! Also, be sure to maintain your compliance with TJC standards to uphold quality and make the next survey easier.
7 Readiness tips for the Joint Commission survey
Here are a few tips to win full Joint Commission accreditation.
1. Study the manual
You can purchase the manual prior to your application. Once you have applied, you will also find the Survey Process Guide (SPG) on your Joint Commission Connect extranet site. TJC works on improving healthcare standards and publishes updates in the SPG.
2. Get everyone on board
Ensure everyone in your organization—from nursing staff to executives—is well-informed and identifies with the process and the goals.
- Is everyone updated on standards relevant to their positions?
- Does each person know what they should be doing during the event?
Keep people focused on consistent quality care and patient safety through direct efforts such as systematic Safety Moments, posters or cards, attractive meetings, and clear communication.
- Consult in internal meetings to assess your organization’s compliance with the standards.
- Practice Safety Moments, five-minute safety messages that reinforce safety culture and draw attention to potential hazards. They are usually delivered at the beginning of a meeting or shift and presented in creative ways. All staff members take turns presenting Safety Moments.
- Strengthen awareness by distributing cards or posters with key points regarding quality and safety standards and encouraging discussions. Managers can make a game of asking individuals if they remember their points.
The consultation and messages bring quality and safety to the forefront of your institutional capacity and culture.
3. Establish communication plans
Clear communication helps you stay organized and move along efficiently during a TJC survey. Build your survey-specific communication plan well in advance, perhaps including notification templates, such as “TJC surveyors are here!”, a prompt for the hospital survey team.
Run drills so that all team members immediately recognize the messages, know how to respond, and take full advantage of the brief Joint Commission survey preparation window.
4. Go over notes from previous surveys
Study your past survey performance, and ensure you have diligently kept up with all the required improvements you have so painstakingly achieved.
Remember to double-check on changes in standards since then to ensure current compliance.
5. Check documentation
A large part of the survey will be on record management. To help you have the records updated and at your fingertips, keep a documentation checklist and review it periodically.
6. Appoint survey teams for each shift
As the survey time approaches, you will not know precisely when it will begin, so create survey teams for different shift times. Select friendly, helpful staff members who know the organization well to provide optimal support to the surveyors.
7. Conduct a mock Joint Commission survey
Conducting a trial run familiarizes both new and experienced staff with the potentially intimidating survey process. A full-scale drill or even a classroom simulation can make the survey day go much more smoothly.
Frequently asked questions about the Joint Commission
There is still much to learn about the Joint Commission; read on for the answers to the most commonly asked questions.
What is a Joint Commission tracer?
A Joint Commission tracer is a tool TJC uses during healthcare organization surveys to evaluate compliance with its standards. It involves "tracing" a patient's journey through the healthcare system, using the patient's record to see how care, treatment, and services were delivered from start to finish. This method helps surveyors spot any gaps or problems, whether within one or more steps of the care process or in connections between parts of the system.
TJC also uses system tracers to see how a system functions and program tracers to focus on specific programs or topics.
How often are surveys? Can they be unannounced?
Yes, the accreditation surveys are unannounced. The surveys are about once every three years for most organizations and every two years for laboratories.
What documentation should I have ready?
Please see the complete list of required documentation in the manual. However, here are a few examples of what you should have ready:
- A license or Clinical Laboratory Improvement Amendments (CLIA) certificate
- Organizational chart and key contact list
- Environment of Care and Life Safety documentation, now merged into the Physical Environment chapter of the manual (updated standards effective in 2026)
- Minutes from the quality committee and other related meetings
- Policies and procedures related to patient safety, infection control, medication management, and emergency preparedness
- Performance improvement data and infection control surveillance from the past 12 months to show ongoing quality monitoring
- Lists of departments, units, services, and current patient information to support tracer activities during the survey
- High-level disinfection and sterilization sites
- Medical staff credentialing, competency assessments, and staff training records to confirm qualified personnel
The above is not an exhaustive list. The manuals for each type of healthcare organization provide a complete list of documents.
It’s to your advantage to be ready to upload survey-related documents electronically via the Joint Commission Connect extranet site for greater efficiency during the survey.
The first and simplest information you will provide to the surveyors is the list of staff members who will escort and assist them in the survey.
Who should attend the opening conference?
The senior leadership, such as the CEO, chief medical officer, chief nursing officer, and governing body representatives, should attend the opening conference to engage with the surveyors, share key information, and clarify expectations for the survey process. Those appointed to accompany the surveyors should also be there, ready to begin.
How should we prepare for RFIs?
At the close of the on-site survey, you will receive a report that includes any Requests for Improvement. You will have a limited time to make the improvements and present evidence that you are in full compliance. Start immediately and use TJC’s SAFER™ Matrix to prioritize which RFI to address first when developing corrective action plans.
Explore more facility guides by Nursa
Nursa provides this guide to help you have a smooth TJC accreditation process.
Explore other articles by Nursa across various staffing and facility management topics:
- Getting a five-star CMS rating
- Proper shift reporting and hand-offs
- Staffing efficiency
- Quality improvement in nursing
- Improving the patient care experience in hospitals
Beyond providing informative guides, Nursa can support readiness teams with flexible nurse coverage during mock surveys or tracer sessions. This keeps care up to par while some regular staff members are busy with the survey and prevents burnout.
Above all, Nursa helps you meet optimal staffing standards for high quality and safety, an important issue for TJC accreditation.
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