Joint Commission Survey 2025: Day 2 Recap

~ Update for Wednesday, Aug. 13 ~

The Joint Commission continued surveying patient care activities in the medical center, clinics, and home care settings.

On Tuesday, the surveyors visited the following areas: Hospice, Home Care, Home Infusion, including home visits; Perioperative Services, including the Central Processing Unit (CPU) and Children’s Surgery Center, Transplant Services; Labor and Delivery Unit, East 4 and East 6, Placer Center for Health, Point West Clinic, and Pharmacy Services Center, including Non-Sterile and Sterile Compounding.

Beginning Wednesday, we anticipate the Joint Commission’s activities will include visiting: 48X and Same Day Surgery, Dialysis Unit, Intensive Care Units, Radiology and outpatient clinics. 

If you are approached by a surveyor and asked a question, please respond openly and thoroughly.  in detail. This is your chance to demonstrate your commitment to excellent patient care as well as your knowledge and skills. If you don’t know the answer, it’s perfectly acceptable to say you will check with your manager.

A few key points to keep top of mind:

• Ensure accurate medication reconciliation

• Remove tape and tape residue from equipment and floors

• Confirm equipment and patient furniture have no cracks, tears, or holes to allow proper disinfection

• Keep extension cords off the floor to avoid tripping hazards

• Empty full red waste bins promptly

• Label multi-use products with both the open date and expiration date

• Identification of ceiling tile replacements

• Ensure proper latching of door closures

• O2 Cylinders should be secured and stored in proper/designated locations

While the Joint Commission survey is a thorough review, it also provides an opportunity to highlight our patient-centered care, showcase our teams’ expertise, and identify areas for improvement—helping us deliver the exceptional care our patients deserve.

Thank you for your continued efforts and all you do for our patients and each other.

~ Update for Tuesday, Aug. 12 ~

Joint Commission Survey 2025: Day 1 Recap

The unannounced, triennial reaccreditation survey by the Joint Commission finished its first day on Monday, Aug. 11. The five-day survey will finish by noon on Friday, Aug. 15.

The 14-person survey team includes administrators, nurses, physicians, pharmacists, and two life safety engineers who have held leadership positions at hospitals throughout the U.S. 

Members of the survey team visited the following areas on Monday:

•    Roseville Clinic
•    Midtown GI Lab
•    Cath Lab
•    PICU
•    NICU
•    CTICU
•    Labor and Delivery 
•    J Street Pulmonary 
•    Prenatal Clinic(s)
•    Cancer Center South
•    And additional clinic locations

On Tuesday, the surveyors will focus on Perioperative Services, including the Central Processing Unit (CPU) and Children’s Surgery Center, Transplant Services, and Pharmacy Services Center, including Non-Sterile and Sterile Compounding. 

As a reminder, if approached and asked a question by a surveyor, please answer openly and thoroughly. Remember your commitment to patient safety and demonstrate your skills and expertise in performing your job. If you don’t know the answer, it’s okay to say you will ask your supervisor or review the policy. 

One surveyor shared, “All staff I interacted with were eager to participate in the survey and represented the organization well.”

Participation in the survey process is an important tool that helps our organization identify areas we can target as opportunities for improvement, such as:

•    Ensure doors latch properly and are not propped open.
•    Hallways are clear and free of equipment, with no corridor clutter.
•    Gas shut-off valves should be easily accessible with no objects obstructing or impeding access.
•    Confirm crash carts have been checked, are locked, and have an inventory list available.
•    Sterile instruments in peel packs have instruments in the open position, don’t have peeling tape, and the package is intact.
•    Ensure all supplies and products with expiration dates are not expired.
•    Patient Care Plans are up to date in EMR system
•    Pain assessments are completed for initial assessment and reassessment per UCDH policy.

Although the survey process can be challenging, it truly measures our commitment to patient safety and quality of care. Thank you for your dedication to our patients and one another.  

~ Update for Monday, Aug. 11 ~

The Joint Commission arrives at UC Davis Health

The Joint Commission, a nonprofit organization that accredits more than 22,000 health care organizations across the U.S., arrived this morning for its unannounced survey of UC Davis Health. The survey, which takes place every three years, will continue through Friday, August 15, and includes visits to the medical center and clinics.

During the five-day survey, surveyors will be on-site to trace patient experiences in our hospital and clinics. They will speak to the doctors, nurses, and other staff interacting with patients, observe patient care, review policies and HR records, and talk to patients. In addition, they will focus on infection prevention, the care environment, medication management, data use, documentation of care, and patient safety practices. UC Davis Health’s participation in the survey reflects our commitment to providing safe, high-quality patient care.

Our teams have been planning and preparing for the Joint Commission’s visit. If a surveyor asks you a question, below are some helpful tips:

• Familiarize yourself with the Joint Commission’s National Patient Safety Goals.
• Review basic information from our annual Joint Commission training requirements, such as safety, privacy, and security training.
• Ensure you know where key reference manuals, such as the disaster plan, the building evacuation plan, and material data safety sheets, are in your department.

Please speak to your manager or supervisor if you have any questions about the upcoming Joint Commission visit. The Insider will share updates regarding the survey as they become available.