The window is now open: YNHH preps for Joint Commission survey visit

As of Sept. 1, the window for The Joint Commission (TJC) accreditation survey opened at Yale New Haven Hospital. Here are a few things you need to know:

Why does TJC conduct a survey?

YNHH is one of the 22,000 hospitals, healthcare organizations and programs accredited by TJC. Accreditation demonstrates to our patients that we adhere to the highest standards of safety and quality with a focus on continuous improvement. TJC accreditation surveys happen every three years.

Although accreditation is not a requirement for a facility to operate, hospitals that accept patients with Medicare or Medicaid insurance must meet conditions of participation mandated by Centers for Medicare and Medicaid Services (CMS) to receive reimbursement. CMS requires that these hospitals have accreditation from one of 10 accrediting organizations, such as TJC. Hospitals that do not pass the survey risk losing these reimbursements.

When will the survey take place? How long will it last?

The accreditation survey will happen without advance warning. Because YNHH is a large, complex organization given its inpatient, outpatient and ambulatory sites, the survey will last five days with the survey team arriving on a Monday morning. It must occur before the end of February 2026.

What happens during the survey?

Surveyors assess the quality of care, treatment and services delivered to patients by interviewing and observing staff across units and facilities throughout the day.

The TJC survey team checks for clinical care provision done safely, infection prevention and control practices, emergency preparedness, medication administration processes, safety event reporting protocols, staff competence and our adherence to guidelines set by regulatory bodies in health care. These are a few examples of what the survey team will look for during their rounds:

• Expired and unsecured medications and supplies
• Documentation of clinical care
• Improper use of single-use items
• Cleanliness of devices such as glucometers and ultrasound
• Exposed wires and broken outlets
• Staff who are unable to explain the RACE/PASS fire safety procedures 
• Staff who are wearing surgical attire outside of the surgery suites   
• Clutter in corridors, hallways and stairways 
• Blocked or obstructed exits or fire doors

The survey team also assesses how we care for patients and document their treatment from hospital admission until discharge. To do this, the surveyor will randomly choose a patient to investigate, look through their medical records and interview staff involved in their care. The surveyor may also speak with the patient directly.

All employees should be prepared to participate in the survey process, even if you are not a frontline staff member engaged in direct patient care.

What are we doing to prepare for the survey?

Senior leadership is rounding every Friday from 10 am to noon to assess regulatory readiness, identify and escalate identified challenges. During rounding they also support unit leaders for surveyor interactions and model accountability and best practices.

Directors should round weekly to address or escalate any issues of concern. Department managers should round in their units every day. In addition, medical directors should round with their clinical partners at least twice weekly.

Download and use the resources provided by Accreditation and Regulatory Affairs (ARA), including the Visual Guide to Deficiencies, the Daily Readiness Checklist, the Day of Survey Readiness checklist, Common Surveyor Questions and the Safety Matters library.

These resources are available on the ARA department intranet page (under both “A” and “R” in the Departments & Communities drop-down menu).

What should I do to be ready for the survey?

Talk to your manager about survey preparedness tasks specific to your role. Ask questions during daily huddles. When senior leaders round on your unit, provide feedback and input about how preparation is going.

If you have questions, concerns or need help locating resources on the intranet, contact David Depukat, director of Accreditation and Regulatory Affairs, YNHH, at [email protected], or call 203-688-9913.