The Joint Commission standards provide the basis for an objective evaluation process that can help healthcare organizations measure, evaluate and improve performance. These standards focus on organizational functions that are critical to providing safe, high-quality healthcare services. The Joint Commission standards establish the expected goals of an organization's reasonable, achievable, and detectable performance. Only new standards related to patient safety or quality of care that have a positive impact on health outcomes and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develops these standards. The survey process is designed to be unique to each organization, consistent, and supportive of the organization's attempts to improve healthcare delivery. During the investigation, the Joint Commission evaluates the performance of processes aimed at improving patient outcomes. The assessment is performed by evaluating an organization's compliance with the standards contained in the manual based on the following key functions: Tracking of care provided to patients Verbal and/or written information provided to the Joint Commission Visual observations and interviews performed by Joint Commission inspectors Documents provided by the Joint Commission organizations“Joint Commission investigations are not announced, with a few exceptions, such as those with the Bureau of Prisons or Department of Defense facilities. An organization may conduct an unannounced survey between 18 and 39 months after the previous full survey. For example, if an organization's last survey was conducted on January 1, 2009, it could conduct it as early as July 1, 2010, or as late as April 1, 2012 (18 to 39 months)." The decision-making process... . half of the document......internal regulatory accreditation investigation that was coordinated and conducted by Allina regulatory managers across the system. The investigations are designed to replicate an actual Joint Commission investigation by incorporating the same patient tracking methodology used by TJC. Non-compliant internal results were evaluated by responsible parties and corrective actions were implemented to bring the requirements into compliance. The results of the internal survey were entered into the ARAS tool and became useful additions during the preparation of the 2010 PPR. A heart failure disease-specific certification team worked diligently throughout the year to prepare the organization for a 2011 TJC Certification Survey. The application for the Heart Failure Program Certification Survey was submitted to TJC in December 2010 with an anticipated site visit at the outset 2011.”