The accreditation survey process with The Joint Commission can be arduous. Furthermore, going through the survey process during the COVID-19 pandemic presented an entirely new challenge. The survey is completed every three years as required by The Centers for Medicare and Medicaid Services, or CMS. UF Health Jacksonville learned the survey team would be on campus for the five-day tour beginning Dec. 13, 2021, and swiftly started preparing for the unannounced visit accordingly. While the survey was more than six months delayed because of pandemic-related challenges, the survey process is always a hospitalwide process.
Hospitals are surveyed to ensure they are meeting strict safety standards for patients, staff and visitors, as set by CMS. Currently, there are over 250 accreditation standards across 18 “chapters” in the CMS hospital accreditation manual. The chapters range from infection control standards to medication management standards to fire sprinkler testing and a host of other facility standards. Due to the ongoing pandemic, however, accreditation organizations have fallen behind on their survey schedules, like we experienced at UF Health Jacksonville. Since it typically takes a hospitalwide effort to get through the survey successfully in normal times, facing this survey when more than 18 months into the pandemic was particularly challenging.
The Joint Commission team surveyed our Home Health program, both hospital campuses and our hospital-based clinics all over Northeast Florida. In total, approximately 90% of the hospital departments and clinics were surveyed. UF Health Jacksonville was surveyed for 284 standards, 1,544 elements of performance and 3,598 CMS conditions of participation.