Accreditation Bulletin: COVID-19 Impact Assessment and Survey Process

Wednesday, July 01 2020

The Joint Commission International (JCI) Hospital Standards promote continuous, systematic and organization-wide improvement in daily performance and in outcomes of patient care. It is JCI’s expectation that all hospitals will maintain compliance with the JCI standards in a way that provides safe, quality patient care during the pandemic.

JCI acknowledges that COVID-19 has had a significant impact on many healthcare organizations, healthcare workers, families, and communities. The impact of COVID-19 falls on a continuum, some hospitals have been drastically impacted by the virus and others have had little to no impact.

To help determine where a hospital falls on the impact continuum, JCI has developed a COVID-19 Impact Assessment survey in the form of an Excel spreadsheet. The Team Leader will send the COVID-19 Impact Assessment to the Survey Coordinator with a request to complete and return the COVID-19 Impact Assessment at least two (2) weeks prior to the start of the scheduled survey.

The completed COVID-19 Impact Assessment provides an objective measurement in the form of a numerical score, indicating no, low, moderate, or high impact. This information will be used by the survey team to help determine the necessary adjustments to the survey process. There will be a new session added to validate the COVID-19 Impact Assessment.

For organizations with no or low impact, the session will be 30 minutes. For organizations with moderate to high impact, the session will be 90 minutes.

JCI recognizes that hospitals that have had moderate to high impact from the pandemic will likely have interruptions in non-critical activities, such as:

  • Data collection, aggregation and analysis in selected areas
  • Inspection and maintenance of non-critical equipment
  • Completion of medical record audits

In addition, other activities, for example, elective invasive procedures/surgeries or annual physical examinations, may have been temporarily suspended. Based on the impact of the COVID-19 pandemic, hospitals undergoing an initial or triennial survey through July 2021 may experience a break in their 6 or 12-month track record during the highest volume COVID-19 month(s).

Depending on the level of impact, the JCI survey team will consider allowances for interruptions of:

  • One to three months in a hospital's track record for triennial survey
  • One to two months in a hospital's track record for initial surveys

These interruptions in the track record due to COVID-19 will not be considered non-compliant. However, if interruptions have occurred, the hospital is expected to provide a plan to return to full compliance and show documentation of progress. Please contact with any further questions.