Top 12 Survey Readiness “To Dos” for 2025

Consider hosting a mock drill to ensure your Command Center operates as expected.  Think about establishing roles and assignments such as (1) Policy & Procedure Management, (2) HR and Med Staff File Management, (3) IOU Tracker, and so forth. Make certain that the Command Center is close enough to the survey team but far enough from the survey team to allow privacy and confidentiality.  Pre-establish a boxed lunch with your cafeteria so that Command Center team members and survey escorts can easily relax, have lunch, and update the command center team while their surveyors are enjoying their private lunch. Remember to plan for DOUBLE the number of surveyors in case your organization is chosen for a Direct Observation Validation Survey (DOVS). In addition, many of the accrediting organizations send field supervisors to observe their surveyors in the delivery of services.  You may need an extra seat or two.

This could take a lot of work, but it will ultimately pay off.  Make sure to embed your contracted vendor services into your operational structure.  If a vendor is providing patient care, they should actively participate in your Patient Care Committees; the performance expectation data that your vendors are measuring for contracting purposes needs to flow to your QAPI Committee, Medical Staff Committee(s), and Governing Body and those committees should be providing feedback to the vendor as needed. Remember, performance expectations need to focus on quality and safety, not simply volumes.

If your organization does not use an external vendor to assess your organization’s compliance with your accrediting organization’s requirements, the use of standardized checklists is essential to ensure a uniform and consistent assessment process. Visit the C&A website to see our Accreditation Resource Companion, the ARC. It contains many free tools, as well as our subscription package, which provides access to over 75 checklists, tools, forms, and gadgets to help you organize and execute your internal assessment process.

In 2025, The Joint Commission is encouraging organizations to migrate to electronic document management as a component of their sustainability pledge.  The Joint Commission is creating an Accreditation Document Upload platform where organizations can upload all of the Requested Documents for the survey listed within the Survey Activity Guide.  It is important to note that CMS will not allow TJC to let you upload documents into their portal until the first day of your survey.  But, as a work around you can establish a location on your internal ShareFile, SharePoint, and Teams sites, to name a few, and simply grant your surveyors access to the documents through these folders.  If you choose to do this, make sure to assign responsibility for uploading new and/or revised policies and remove outdated policies, and of course, remember to terminate the surveyor access once the survey is over!

Nursing staff must ensure that patient care plans are started within 24 hours of admission.  They should include any problems or potential patient problems related to their diagnosis/surgical procedure, etc.  Interventions to be taken need to be relevant to the patient's condition, dated, and timed with a target goal for completion.  This goal can be revised as needed.  Spot-check your new admissions to ensure these care plans have been initiated.  Review to see if they reflect the patient’s needs based on assessments and diagnosis.

Not only is it essential for all staff to know what your policy and procedures say, it is also necessary for them to understand what the instructions for use say regarding the equipment, solutions, and other essential items used for patient care.  The instructions for use will provide you with how to clean, store, and maintain these items.  IFUs can be either paper or web-based, depending on the organization, and should be reviewed annually for any changes.  Review your IFUs to determine if they are current.  Ask staff if they know how to access them.  Spot check to see if staff are following them for cleaning of equipment, use, and periodic function checks as indicated.

Rounding is a necessary evil in healthcare; we work in the environment every day and frequently do not always see what needs to be done in our areas to be survey-ready all the time.  Rounding should be done often with a multi-disciplinary team.  This team should include, at a minimum, quality staff, infection control, pharmacy, environment of care, security, nursing, and department directors/managers. Findings on rounds should be shared with the areas where the deficiencies are found.  Review your current process for rounding.  Who is participating in rounding?  Is it broad enough in the spectrum of disciplines and leadership?  Are the findings shared?  Are these findings aggregated to identify trends?

Whenever sterile instrumentation is used, inspecting those instruments before use is essential.  This starts in your Sterile Processing Department (SPD) and should filter up to the provider who is using the instrument.  SPD should be doing a detailed inspection of all instrumentation before sterilization.  This includes checking for any residual bioburden, blood, and cement, as well as for rust, scratches, cracks, sharpness, and alignment of the instruments.  If instrument tape is used, it should be applied per the IFU.  Review your instrument inspection process.  Spot-check processed instruments for opportunities.  Ensure you review those instruments in remote areas that may not circulate as frequently.

Storing and maintaining supplies in carts, response bags, and other decentralized locations can provide convenient access for staff.  However, many expired supplies are found in these locations as staff often struggle to maintain them.  The time used to perform supply checks can add up.  Consider reviewing your use of supply carts and, if they are needed, streamline the amount of supplies to reduce the time your team spends on looking for expiration dates and maintaining them.

Cleaning and disinfection of ultrasound probes should be aligned with the manufacturer IFU and Spaulding’s Classification, which matches the cleaning/disinfection level with exposure risks.  We are noticing many organizations with probes coming into contact with non-intact skin that perform low-level disinfection. This can result in a potential risk of blood-borne pathogen transmission as these devices should undergo high-level disinfection.  Review your ultrasound probe IFU to ensure you follow effective practices to prevent bloodborne illness transmission.

Addressing patient safety risks require organizations to review patient safety data, analyze the data, prioritize the risks, and create an action plan to address these prioritized risks.  Accrediting organizations are taking a more critical position in reviewing the organization’s processes for identifying and addressing risks.  Ensure your organization is aggregating patient safety data (from incident reporting to safety audits) and providing analysis of the data to identify those issues that should take precedence for action.  Validate that your action plans have been initiated and you have data to show if the plan is effective.  Educate and involve your staff on these initiatives so they can speak to them when approached by a survey team.

The time spent providing patient care frequently does not allow for deep cleaning and reorganization of supplies and equipment. Supplies and other items find their way into forgotten drawers and cabinets that expire or have passed their biomedical engineering safety checks. Take the time to go through all the nooks and crannies in your work center to find and remove items that should be discarded, relocated, or maintained.