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Outpatient Surgery E-Weekly

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Home > Archive > December 2003
Ask Caryl
Fast Facts About Random, Unannounced Surveys
Caryl A. Serbin, RN, BSN, LHRM

Caryl A. Serbin, RN, BSN, LHRM Q What can you tell me about random, unannounced Joint Commission on-site surveys?

A By 2006, all JCAHO regular surveys will be unannounced. It's important to emphasize, though, that initial surveys, even after 2006, will be on an announced basis. Some other facts about random, unannounced surveys:

  • For 2004 and 2005, while JCAHO pilot-tests unannounced surveys in volunteer organizations, you'll receive no advanced notice of a random re-survey.
  • Re-surveys can be conducted from nine to 30 months after your triennial survey. Starting in 2006, unannounced surveys will occur within the calendar year that your re-survey is scheduled. The JCAHO Board may expand this window.
  • JCAHO will randomly select 5 percent of organizations accredited through the end of 2003 for unannounced one-day, one-surveyor re-surveys. Starting in 2006, 100 percent of re-surveys will be unannounced.
  • Surveyors who are specially trained in the use of the random, unannounced survey protocols will conduct the unannounced surveys.
  • Per current policy, re-survey results may lead to new Type I recommendations and may even cause a change in the organization's accreditation status.
  • Per current policy and continuing for 2004 and 2005, there will be no cost for an unannounced re-survey.
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