Skip to main content Back to Top


JCAHO Selects Elements for Random Unannounced Surveys

Cheryl A. Thompson

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently announced the performance areas that would likely be assessed in 2001 during surveys conducted without prior notice 9 to 30 months after the most recent full onsite evaluation. Medication use is one of the top areas that will be assessed during random unannounced surveys of hospitals and ambulatory care and behavioral health care organizations; medication administration is a top survey area for hospice services provided by home care organizations.

Under JCAHO's program of random unannounced surveys, 5% of organizations accredited under the hospital, home care, ambulatory care, long-term care, or behavioral health accreditation program are reevaluated without prior notice. Surveyors first assess performance areas noted as needing improvement in the organization's most recent accreditation survey report, any complaint or performance data received since the last full survey, and other information discovered onsite during the unannounced visit. Then surveyors assess, as time allows, the top five or six performance areas identified by JCAHO as "high risk" among organizations in the particular accreditation program. These performance areas constitute the "fixed" elements for the unannounced surveys and change each year.

The fixed elements are available online at; some of the elements related to pharmacy practice are as follows:

  • Competence assessment, for ambulatory care organizations,
  • Medication use, for ambulatory care and behavioral health care organizations and hospitals,
  • Planning and provision of care, for home care organizations,
  • Infection control practices, for home care organizations,
  • Medication administration, for hospice services provided by home care organizations, and
  • Orienting, training, and educating staff, for hospitals.

The fixed elements were selected by JCAHO for various reasons. Often, the Joint Commission said, an element was chosen because a high percentage of organizations had been cited for serious deficiencies ("type I recommendation") in that performance area, statistics for complaints or sentinel events indicated a problem, or issues of public concern had been raised. JCAHO said that surveyors might not have time to assess all of the fixed elements during a random unannounced survey and may instead focus on the highest-priority ones.