Disputed Survey Findings

Whenever you feel The Joint Commission (TJC) surveyors have mistakenly cited you for a Life Safety Code® violation or Environment of Care (EC) standards issue, what steps should you take before this issue becomes a part of the official accreditation report as a Requirement for Improvement (RFI)? 


The following suggestions might help avert any unwarranted citations.

1) If you have any additional information that would demonstrate compliance with a Life Safety Code® or EC standard that a surveyor has indicated may be an RFI, you should supply that information to your surveyor(s) as soon as possible. The Hospital Accreditation Manual’s chapter, “The Accreditation Process,” has a section entitled “Feedback Sessions” and states, “Surveyors will communicate their observations at daily briefings, if requested to do so by the organization. If the organization has additional information that would demonstrate compliance that a surveyor has indicated may be an RFI, the organization should supply that information to the surveyor(s) as soon as possible.”

2) At your earliest opportunity, refer to the Life Safety Code® or your accreditation standards manual and, together with the surveyor, review and discuss the applicable section(s) and specific requirements. If this does not resolve the matter, ask that the survey team leader be brought into the discussion. If the issue is still not resolved, and you feel you are clearly meeting the code or standard’s requirements, then you need to request that the surveyors contact TJC’s Standards Interpretation Group (SIG). Ask the surveyors to initiate the call and use their special 800 number which should put your call to the head of the SIG calling queue. With the surveyor present, you may state your case and ask the appropriate SIG unit member to provide the necessary clarification for all who are part of the conference call.

In order to avoid any unwarranted RFIs: a) be proactive and don’t be afraid to request that the surveyors communicate their observations at daily briefings; b) provide whatever additional information, data, or other documentation that might validate your compliance efforts; c) ask the surveyor(s) to look at the Life Safety Code or accreditation manual with you to discuss the specific requirements; and finally, d) if necessary, ask your surveyor to call TJC Standards Interpretation Group to get the needed clarification and final word.