August 15, 2025
Joint Commission Survey 2025: Results
Dear Colleagues,
I’m proud to share that our 2025 Joint Commission Survey was a tremendous success. It was one of the strongest results UC Davis Health has achieved to date.
This outstanding outcome directly reflects your commitment, talent, and daily pursuit of the highest standards of patient care. I extend my sincere thanks and congratulations to everyone, especially to Kimber Ramos, Director, Regulatory, Licensure and Accreditation, and her team, who supported the survey process so expertly.
As expected, the survey team identified a few opportunities to further strengthen our practices. Many of these were managed in real time during the visit, and the remaining findings will be promptly addressed.
Our health system is a large and complex organization, yet we approach challenges with remarkable unity. During the survey, it was clear how thoroughly prepared our staff were. Every team member was ready to engage with the surveyors, and the level of interaction and enthusiasm was truly inspiring to witness. The surveyors saw what I already know: your skills, knowledge, and collaboration are outstanding. It’s what makes UC Davis Health such an extraordinary organization.
The Joint Commission Survey offers a valuable snapshot of our performance at a single moment in time, yet it also reflects the sustained dedication, diligence, and excellence you demonstrate every day across the three years between surveys.
The survey can be challenging, and I know it requires significant preparation and focus. Thank you for your professionalism, attention to detail, and most of all, the exceptional care you provide daily to our patients.
With thanks and appreciation,
Joseph Galante, MD, MBA
Chief Medical Officer
UC Davis Health, Hospital Clinical Care Services
Professor of Surgery
University of California, Davis
~ Update for Friday, Aug. 15 ~
On Thursday, Joint Commission surveyors continued their review by visiting additional community clinics and areas throughout the Medical Center. They shared that it has been a wonderful experience interacting with our engaged and passionate employees. One surveyor noted, “Staff members were able to articulate what they were doing and the why behind it.”
The day’s activities included:
- Medical Staff Credentialing & Privileging
- 48X Perioperative Services
- Compounding Pharmacy
- Community-based Palliative Care
- Discussions regarding antimicrobial stewardship and the anticoagulation program
- Emergency Management
- Quality & Performance Improvement
Friday marks the final day of the triennial survey. In the morning, surveyors will present their findings and highlight best practices to health system leadership. The visit is expected to conclude by noon.
Thank you for your continued dedication and exceptional efforts throughout this important survey process.
~ Update for Thursday, Aug. 14 ~
Joint Commission Survey 2025: Day 3 Recap
The Joint Commission’s survey continued Wednesday, with one surveyor remarking, “Your staff is very engaged and ready to answer questions.” Surveyors spent the day reviewing documentation and policies, and visiting the following areas:
- Ambulatory Care Center (ACC)
- Same Day Surgery Center
- Emergency Department
- Radiology
- Burn ICU and NSICU
- Medical/Surgical Unit(s)
- Food and Nutrition Services
- Dialysis
- Pharmacy Services
- Transplant Services
- Hospice, Home Care, and Home Infusion
- Inpatient Community-based palliative care
- Folsom, Roseville, and Cypress Clinics
On Thursday, we anticipate the surveyors will visit the following areas and conduct the following sessions:
- Medical Staff Credentialing & Privileging Session
- Quality & Performance Improvement Session
- Ambulatory Clinic Sites
~ Please remember ~
- It’s OK to say you don’t know an answer - ask your manager or refer to a UCDH policy.
- Ensure equipment does not block access to electrical panels, fire extinguishers, or eye wash stations.
- Check for dust on high-level surfaces.
- Verify that all medication locations are secured and locked.
A surveyor also identified the RN-Driven Discharge Process in the PACU as a best practice for improving bed flow and recognized it as an innovative approach to optimizing space, staff, and ensuring quality and safe patient care.
Thank you to everyone engaging with the surveyors, answering questions, and sharing information about our health system. Each team member contributes to the exceptional patient care our patients receive at UC Davis Health.
~ Update for Wednesday, Aug. 13 ~
Joint Commission Survey 2025: Day 2 Recap
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.
