Surgery Center Accreditation or Medicare Deem Status. Prepping for a Joint Commission Survey: How to Get Your Surgery Center Inspection-Ready!

May 11, 2025

Surgery Center Accreditation or Medicare Deem Status. Prepping for a Joint Commission Survey: How to Get Your Surgery Center Inspection-Ready!

Preparing for a Joint Commission survey doesn’t have to be stressful — if you know what to expect and how to stay ready year-round. At Accredia Surgery Center Accreditation Consulting, we help surgery centers like yours confidently navigate the accreditation process by breaking down the complex requirements into manageable action steps.

Here’s a focused checklist to help you prep efficiently for a Joint Commission inspection:

1. Keep Your Policies & Procedures Updated

Surveyors will review your policy manual — not just for completeness, but for how well your team follows it. Ensure your documents reflect current Joint Commission standards and state/federal regulations. Review them at least quarterly, and make sure staff know where to find them.

2. Conduct Mock Surveys

Routine internal audits or mock surveys are essential. Walk through the center as if you’re a surveyor — check environment logs, clinical charting, equipment, credentialing files, staff files and signage. These dry runs build team readiness and uncover gaps before they become deficiencies or Condition Level citations.

Bonus: Invite an external consultant, Nicole Brown of Accredia for a mock survey to simulate the real experience.

3. Document Daily Operations Thoroughly

Surveyors love documentation. Ensure logs are complete: temperature checks, cleaning checklists, chemical list with EPA numbers, time-outs, consents, infection control practices — every detail counts. Incomplete or inconsistent records can raise red flags.

Quick Fix: Use checklists to standardize documentation and reduce missed entries.

4. Train and Empower Your Staff

Your staff should be survey-ready every day, not just the week of an inspection. Make education a habit — hold brief huddles, provide quick updates on standards, and encourage a culture of safety and transparency.

What to Train On: Fire drills, infection control, sterile processing, patient rights, emergency operations planning, and how to answer surveyor questions.

5. Maintain Your Physical Environment

Joint Commission surveyors are keen observers. Walk your building and correct hazards: peeling paint, damaged doors, rust on carts, cluttered hallways, blocked exits, expired supplies, and unsecured gas tanks. Your facility’s appearance speaks volumes about your safety culture.

Need Help Getting Ready? Contact Nicole Brown of Accredia today!
We offer downloadable Joint Commission-ready policies, procedures, and forms that surgery centers can customize to stay compliant. We also provide mock survey services and a year-round compliance surgery center accreditation preparation TV subscription to keep your accreditation prep on track.

Here’s to your success,

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