By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services
Key Takeaways
Survey readiness begins with a current, facility-specific infection control risk assessment.
Policies should accurately reflect daily practice, and staff should consistently follow those policies.
Surveyors focus on real workflows, including hand hygiene, medication safety, sterile processing, environmental cleaning, and staff competency.
Mock surveys and tracer activities often reveal issues long before an accreditation survey does.
Organizations that identify, correct, document, and monitor infection prevention gaps are generally better positioned for successful survey outcomes.
Preparing for a Joint Commission survey can feel overwhelming, especially when infection prevention is involved. I’ve learned that successful surveys rarely come down to whether a facility has the right binder sitting on a shelf. They come down to whether infection prevention has become part of everyday operations.
I have walked into facilities that felt confident because every required policy was present. Within minutes, it became clear that staff practices, documentation, and leadership oversight did not consistently support those policies. I’ve also worked with organizations that uncovered significant gaps before survey day, corrected them through a structured quality process, and performed exceptionally well — because they understood that continuous improvement, not perfection, is what surveyors are looking for.
The Joint Commission evaluates much more than written documentation. Surveyors observe care as it happens. They interview staff. They trace instruments, medications, and patients through the facility. Most importantly, they assess whether your infection prevention program identifies risks, responds to problems, and continuously improves patient safety.
Three questions drive that evaluation:
Do your policies reflect current evidence-based guidance?
Does daily practice consistently match those policies?
Can leadership demonstrate an effective process for identifying, correcting, and monitoring infection prevention risks?
Whether your ambulatory surgery center (ASC) is preparing for an upcoming survey or simply wants to strengthen its infection prevention program, this checklist covers the areas that deserve the closest attention before surveyors arrive.
Step 1: Begin With Your Infection Control Risk Assessment
Your risk assessment is the starting point for everything else in your infection prevention program. If it doesn’t accurately reflect your facility, the rest of the program can quickly become disconnected from day-to-day operations.
A meaningful assessment should evaluate:
Surgical specialties performed
Types of anesthesia administered
Instrument reprocessing requirements
Implant procedures
High-risk patient populations
Medication preparation practices
Environmental cleaning challenges
Construction, renovation, or water intrusion events
Recent infections, exposures, breaches, or patient complaints
A risk assessment that barely changes from year to year is often a warning sign. Surveyors expect the assessment to evolve as your organization changes — new equipment, additional procedures, staffing changes, updated regulations, and emerging infection risks should all influence how you evaluate your program.
Treat it as a working document, updated whenever your services, staffing, or risks change.
Step 2: Build an Infection Prevention Plan That Reflects Your Facility
Once you’ve identified your risks, your infection prevention plan should clearly demonstrate how you will address them.
Rather than relying on a generic template, develop a plan that reflects your organization’s actual operations and priorities. At a minimum, your plan should include:
Annual infection prevention goals
Surveillance activities
Audit priorities
Staff education requirements
Leadership reporting structure
Performance improvement activities
Corrective action processes
Methods for reviewing and acting on infection prevention data
The CDC’s core infection prevention and control practices identify leadership support, education, hand hygiene, standard precautions, environmental cleaning, personal protective equipment (PPE), injection safety, performance monitoring, and instrument reprocessing as core components of effective infection prevention programs.
What surveyors want to see is how those concepts become daily practice inside your ASC.
A strong infection prevention plan is specific to your facility — your procedures, your patient population, your risks.
Step 3: Make Sure Policies Match Daily Practice
If I could eliminate one recurring issue before every Joint Commission survey, it would be policy-practice mismatch.
Some facilities have excellent policies that staff cannot consistently follow. Others have staff performing procedures correctly while outdated policies describe workflows that no longer exist. Both create unnecessary survey risk.
Common examples include:
A policy requires glucometers to be disinfected between every patient, but staff cannot identify the approved disinfectant.
Medication policies require opened multidose vials to be dated, yet surveyors discover undated vials during observation.
Policies describe transporting contaminated instruments in closed, leak-proof containers, while staff routinely carry uncovered trays through the facility.
Policies reference equipment, disinfectants, or clinical guidelines that have since been replaced.
Before your survey, compare every infection prevention policy against what actually happens during routine patient care.
If the policy is correct, reinforce staff education and competency. If staff are following an improved workflow that isn’t reflected in the policy, revise the policy before surveyors identify the inconsistency.
Accreditation surveys frequently uncover documentation issues that are easily corrected — but only when organizations find them first.
Step 4: Observe Hand Hygiene and PPE Use in Real Time
Hand hygiene remains one of the simplest infection prevention practices to understand and one of the easiest to evaluate through direct observation. Surveyors watch what staff members do. Interviews come later.
The CDC’s hand hygiene recommendations for healthcare personnel emphasize performing hand hygiene at key moments, including:
Before touching a patient
Before clean or aseptic procedures
After contact with blood or body fluids
After touching a patient or the patient’s environment
Immediately after removing gloves
Before your survey, confirm that:
Alcohol-based hand rub is readily available where patient care occurs.
Handwashing sinks remain properly stocked.
Staff understand when soap and water are required instead of alcohol-based hand rub.
Gloves are never treated as a substitute for hand hygiene.
Appropriate PPE is available for anticipated exposures.
Staff can correctly don and doff PPE without contamination.
Watch routine workflows rather than relying on hypothetical questions. Observe pre-operative areas, operating rooms, sterile processing, the post-anesthesia care unit (PACU), medication preparation spaces, and room turnover during a normal day. Those observations almost always provide a more accurate picture of survey readiness than interviews alone.
Step 5: Evaluate Medication Preparation and Injection Safety
Medication preparation and injection safety continue to be among the most closely scrutinized areas during Joint Commission surveys — and for good reason. Small deviations from safe practice can create significant patient safety risks.
In many facilities, staff understand the basic principles of injection safety. The problems usually appear in the details of everyday workflow. Shortcuts become routine. Surveyors notice them.
As part of your survey preparation, review:
Single-dose vial practices
Multidose vial storage and dating
Needle and syringe use
Medication preparation locations
Separation of clean medication preparation areas from sinks and contaminated surfaces
Labeling of prepared medications
Beyond-use dating practices
Anesthesia medication handling
IV tubing and fluid management
The CDC’s safe injection practices recommend preparing medications in a designated clean area that is physically separated from potential sources of contamination, including sinks. Needles and syringes are intended for one patient and one procedure only.
One issue I see repeatedly is medication preparation occurring next to sinks simply because the workspace is convenient. Staff often don’t recognize that splash contamination remains a concern even when the sink appears clean. Organizations sometimes develop strong policies regarding multidose vials, yet staff bring those vials into patient treatment areas out of convenience — and surveyors frequently observe these workflows directly.
Watch medication preparation during a typical clinical day.
Step 6: Follow Instrument Reprocessing From Beginning to End
For many ASCs, sterile processing represents the highest-risk area of an infection control survey.
Surveyors evaluate the complete journey an instrument takes — from the point of use, through decontamination and sterilization, back to the clinical area. That journey includes:
Point-of-use treatment
Safe transport from the procedure room
Decontamination
Manual or mechanical cleaning
Inspection
Packaging
Sterilization
Storage
Transport back to the clinical area
Each step depends on the one before it.
As you evaluate your process, confirm that:
Dirty and clean workflows remain physically separated.
Manufacturer instructions for use (IFUs) are readily available and consistently followed.
Staff competencies are current and documented.
Cleaning brushes and accessories are appropriate, inspected, and replaced as needed.
Enzymatic cleaners are mixed and used according to manufacturer instructions.
Sterilizer documentation is complete and accurate.
Biological and chemical indicator records are maintained.
Loaner instrumentation follows an established process.
Immediate-use steam sterilization is appropriately limited, justified, and documented.
The CDC’s guidance on disinfection and sterilization reinforces that sterile processing is an integral part of clinical care, connected to every other infection prevention practice in your facility.
I have seen facilities prepare sterile processing beautifully for survey day while relying on processes that collapse under normal daily pressure. Surveyors can usually tell the difference.
Step 7: Validate Environmental Cleaning Practices
Environmental cleaning is an infection prevention responsibility, shared across the entire organization.
Surveyors understand that effective cleaning requires coordination across multiple departments. Review your processes for:
Operating room turnover cleaning
Terminal cleaning
Pre-operative and PACU cleaning
High-touch surface disinfection
Shared patient equipment
Required disinfectant contact times
Product compatibility with equipment and surfaces
Assignment of cleaning responsibilities
Documentation of completed cleaning activities
Proper storage of cleaning products and supplies
The CDC recommends using EPA-registered disinfectants appropriately and following manufacturer instructions, including dilution, application method, compatibility, and required wet contact time.
One of the most common findings I encounter is the right disinfectant being used incorrectly. Staff may know which product to use but be unable to state the required contact time, or surfaces are wiped dry before the disinfectant has remained wet long enough to be effective.
Observe room turnover in real time. Ask staff to explain what they are doing and why. Those conversations frequently reveal opportunities for education before surveyors identify them.
Step 8: Review Infection Surveillance and Reporting
Every ASC should be able to explain how it identifies, investigates, and responds to procedure-related infections. That process becomes more challenging in the outpatient setting because patients often recover at home and may seek treatment elsewhere if complications develop.
Your surveillance program should clearly define:
Which infections are monitored
How post-procedure infections are identified
Who reviews surveillance data
How infection trends are analyzed
When physicians are notified
When public health reporting is required
How corrective actions are documented and evaluated
One assumption I occasionally hear is, “We haven’t had any infections.” Surveyors are far more interested in how your organization would recognize a possible infection, investigate it appropriately, communicate findings, and implement improvements.
A credible surveillance process demonstrates that your ASC actively monitors patient outcomes — and has a plan to respond when something goes wrong.
Step 9: Confirm Staff Education and Competency
Training records often receive attention just before a survey, but effective competency assessment should occur throughout the year. Surveyors want evidence that staff members have received appropriate education and can safely perform the tasks assigned to them.
Review documentation for:
Initial infection prevention orientation
Annual infection prevention education
Hand hygiene
Bloodborne pathogens
PPE
Injection safety
Environmental cleaning and disinfection
Sterile processing competencies
Point-of-care testing, when applicable
High-level disinfection, when applicable
Training on new equipment, products, or procedures
The CDC recommends job-specific infection prevention education before personnel begin performing assigned duties, at least annually thereafter, and whenever new risks, products, equipment, or identified deficiencies require additional training.
For higher-risk responsibilities — such as sterile processing, high-level disinfection, or medication preparation — attendance records alone rarely demonstrate competency. Whenever possible, competency validation should include direct observation documenting that staff can perform critical tasks correctly under normal working conditions.
Step 10: Conduct a Mock Survey Using Tracer Methodology
Evaluating your ASC the way a surveyor will is one of the most valuable things you can do before a Joint Commission visit.
That means moving beyond document review and following the actual delivery of care. Tracer methodology allows you to assess whether infection prevention practices remain consistent throughout a patient’s experience and across the systems that support safe care.
Consider conducting tracers that:
Follow a patient from registration through discharge.
Follow an instrument from point of use through decontamination, sterilization, storage, and return to service.
Follow a medication from storage through preparation and administration.
Follow the environmental cleaning process from room turnover through documentation.
Include conversations with frontline staff while observing their normal workflows.
During each tracer, compare what the policy says, what staff describe, and what actually occurs. Ideally, all three align.
The value of a mock survey comes from what it reveals. Real findings, identified internally, give your team time to correct and document before survey day. A mock survey that uncovers nothing often signals the organization wasn’t looking closely enough.
Step 11: Correct Deficiencies — and Demonstrate Follow-Through
Identifying a problem is the beginning of the quality process. Leaving it unaddressed is what draws survey findings.
No infection prevention program is perfect. Surveyors understand that healthcare organizations identify issues from time to time. What distinguishes high-performing organizations is how they respond.
For every infection prevention issue identified, document:
What was observed.
Immediate corrective actions taken.
Root causes or contributing factors.
Staff education or competency validation, if applicable.
Policy revisions, when appropriate.
Follow-up audits.
Evidence that the improvement has been sustained over time.
Organizations sometimes focus on documenting the initial finding while spending far less attention on what happened afterward. Sustained improvement tells a much stronger story than initial compliance. Surveyors are looking for mature quality systems — organizations that recognize risks, address them promptly, and verify that improvements hold.
Step 12: Prepare Both Leadership and Frontline Staff
Survey readiness should never depend on one infection preventionist, one administrator, or one department. The strongest ASCs build a culture in which everyone understands their role in infection prevention.
Leadership should be prepared to discuss:
Current infection prevention priorities.
Recent trends identified through surveillance.
How infection prevention data is reported to governing bodies and quality committees.
Resources dedicated to infection prevention.
How corrective actions are monitored and sustained.
Frontline staff should be comfortable explaining:
Where infection prevention policies are located.
How to report a potential infection prevention concern.
Which disinfectants they use and the required contact times.
Hand hygiene expectations.
Appropriate PPE selection.
Steps to take following an exposure or breach.
Prepare staff to understand the reasoning behind infection prevention practices — why hand hygiene matters at specific moments, why contact time is critical, why workflows follow a dirty-to-clean sequence. When staff understand the why, they answer questions naturally and consistently. That confidence is far more convincing than a rehearsed response.
Joint Commission Infection Control Survey Preparation Checklist
Use this checklist as a practical self-assessment before your next Joint Commission survey.
Infection Prevention Program
Current infection control risk assessment completed
Annual infection prevention plan updated
Program goals reflect the facility’s actual risks
Infection prevention responsibilities clearly assigned
Leadership oversight documented
Infection prevention data reviewed through QAPI and governing body meetings
Policies and Procedures
Policies reflect current evidence-based guidance
Policies match actual clinical practice
Obsolete equipment, products, and procedures removed from policies
Staff know where current policies are located
Policies reviewed according to organizational requirements
Hand Hygiene and PPE
Hand hygiene supplies available at point of care
Staff observed performing hand hygiene appropriately
Gloves never substituted for hand hygiene
PPE readily available
Staff demonstrate correct PPE selection and removal
Medication and Injection Safety
Medications prepared in designated clean areas
Medication preparation separated from sinks and contamination sources
Single-dose and multidose vials managed appropriately
Opened multidose vials dated according to policy
Needles and syringes used for one patient only
Anesthesia medication practices reviewed
Sterile Processing
Dirty-to-clean workflow maintained
Manufacturer IFUs readily available
Staff competencies current
Sterilizer documentation complete
Biological and chemical indicator documentation complete
Instruments stored appropriately
Immediate-use steam sterilization appropriately limited and documented
Environmental Cleaning
Cleaning responsibilities clearly defined
EPA-registered disinfectants available
Staff understand required contact times
Operating room turnover observed
High-touch surfaces addressed
Shared equipment disinfected between patients
Cleaning documentation complete
Surveillance and Reporting
Surveillance process clearly defined
Post-procedure follow-up process established
Infection data routinely analyzed
Required reporting obligations understood
Escalation process documented
Education and Competency
Initial infection prevention education completed
Annual education current
High-risk competencies validated
Training on new equipment documented
Corrective education documented following identified deficiencies
Mock Survey and Performance Improvement
Mock survey completed
Patient tracer completed
Instrument tracer completed
Medication tracer completed
Environmental cleaning tracer completed
Findings documented
Corrective actions completed
Follow-up audits demonstrate sustained improvement
Successfully Navigating Accreditation Surveys
The facilities that navigate accreditation surveys, including those performed by the Joint Commission, well have built infection prevention into the way they operate every day.
For ASCs, that means walking your facility the way a surveyor will — observing care, asking staff questions, tracing instruments and medications, reviewing documentation, and confirming that leadership responds when risks are identified. Survey preparation and good infection prevention practice are the same work.
If your ASC treats accreditation readiness as an ongoing quality process, you’ll be better positioned for survey — and for providing safer care to every patient who walks through your doors.
Preparing for an Accreditation Survey?
ICCS helps ASCs and other healthcare organizations prepare for accreditation surveys by identifying infection prevention gaps before surveyors do. If you’d like an experienced set of eyes on your infection prevention program, a mock survey is often the most effective place to start.
Learn more about our survey preparation services, explore ICCS services for ambulatory surgery centers, or contact ICCS to discuss how we can help.
Frequently Asked Questions About Joint Commission Survey Preparation
How far in advance should an ASC prepare for a Joint Commission survey?
Survey readiness should be an ongoing process rather than a project that begins a few weeks before an anticipated survey. If your organization expects a survey within the coming months, conduct a comprehensive mock survey early enough to identify deficiencies, implement corrective actions, educate staff, and verify that improvements have been sustained.
Which infection prevention areas receive the greatest survey attention?
Although every organization is different, surveyors commonly focus on hand hygiene, medication and injection safety, sterile processing, environmental cleaning, staff competency, infection surveillance, and whether daily practice consistently aligns with written policies.
Are written infection prevention policies enough?
Policies establish expectations, but surveyors evaluate much more — whether staff understand those expectations, consistently follow them, and whether leadership monitors compliance and responds appropriately when deficiencies are identified.
What infection prevention risks are most common in ambulatory surgery centers?
Sterile processing, medication preparation and injection safety, environmental cleaning, and breakdowns between written policy and actual workflow remain among the most frequent areas requiring corrective action. The specific risks for each organization depend on the procedures performed, patient population, equipment, and facility design.
Should every ASC perform a mock survey?
Yes. Mock surveys frequently identify opportunities for improvement that routine audits miss. They allow organizations to correct deficiencies before accreditation surveys while strengthening patient safety and staff confidence.
What if we discover problems shortly before our survey?
Address them immediately. Document the issue, implement corrective actions, provide additional education if necessary, revise policies when appropriate, and perform follow-up audits to verify sustained improvement. Organizations that recognize and correct deficiencies generally demonstrate a stronger quality culture than organizations that appear unaware of their own risks.