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Article Date: 12/01/2007

Elimination of track record requirements and Early Survey Policy -Option 2
Effective January 1, 2008, The Joint Commission will discontinue track record requirements for organizations undergoing initial surveys or reviews. These organizations will not need to demonstrate a four-month track record of compliance with the standards at the time of the initial survey or review. However, initial hospitals that provide surgical or pediatric services must undergo a follow-up on-site survey one year after becoming accredited (with the exception of critical access hospitals that are certified by the Centers for Medicare & Medicaid Services and have had their one-year follow-up survey by CMS). The Joint Commission’s follow-up survey is limited in scope, focusing on only those areas that are most important to the provision of patient care in each of the identified high risk services (e.g., medication management, infection control). For hospitals and critical access hospitals, the current track record requirements for re-surveys or re-reviews are: 12 months with a score of 2 (satisfactory compliance); 6 to 11 months with a score of 1 (partial compliance); and fewer than 6 months with a score of 0 (insufficient compliance). Please note that track record requirements remain in place for organizations undergoing re-surveys or re-reviews. For more information, see the September issue of The Joint Commission Perspectives.
Also effective January 1, 2008 and related to this action is the elimination of Early Survey Policy—Option 2 for all programs (except the laboratory program). This option permitted the conduct of two full surveys at an organization, the first to assess compliance with all applicable standards at the time of survey, and the second to assess the organization’s ability to demonstrate sustained compliance over a four-month period.

Website Address: http://www.jointcommission.org

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