Compliance News: TJC News Brief on Shortened Survey Time Frame

By Dean Samet, CHSP


The Joint Commission announced in the November 17, 2010 Joint Commission Online that effective Jan. 1, 2011, full survey time frames will change from 39 to 36 months (see note below) for all accreditation programs (except the laboratory accreditation program). TJC will conduct an organization’s full survey within 36 months instead of 39 months after its previous full survey primarily to maintain consistency in the timing of the survey window with the Centers for Medicare & Medicaid Services (CMS).


Note: Previously, per the 2010 Hospital Accreditation Standards manual, The Accreditation Process chapter, section Duration of Accreditation Award, “An accreditation award is continuous until the organization has its next full survey, which will be between 18-39 months after its previous full survey, unless accreditation is revoked for cause or as otherwise outlined in this chapter.” In the same chapter under the Duration of the Accreditation Decision, “An organization’s previous accreditation decision remains in effect until a decision is made either to accredit or to preliminarily deny accreditation to the organization.”