Can you fail Joint Commission?
People talk about a Joint Commission survey like it’s a test you “pass” or “fail.” In reality, it’s a risk-based accreditation process with specific accreditation decisions—and yes, it is possible to end up denied (which is what most people mean by “fail”).
The real answer: you don’t “fail the survey”… you can lose accreditation
At the exit conference, surveyors review preliminary findings, but they do not predict your final accreditation decision. The final decision comes after post-survey steps (like your ESC submission and internal review).
The Joint Commission’s accreditation decisions include outcomes like:
Accreditation
Accreditation with Follow-up Survey
Preliminary Denial of Accreditation
Denial of Accreditation
So, can you “fail”? If by fail you mean end up in Preliminary Denial or Denial—yes.
What usually triggers a “bad outcome” (Preliminary Denial / Denial)
Joint Commission lists several situations that can justify Preliminary Denial of Accreditation, including:
Immediate threat to health or safety to patients or the public
Falsified documents or misrepresented information
Lack of a required license (or similar issue) at the time of survey
Failure to resolve requirements tied to an Accreditation with Follow-up Survey status
Significant noncompliance with standards
“Preliminary Denial” is subject to review and appeal before a final denial decision.
Where the SAFER Matrix fits in (and why it matters)
Joint Commission uses the SAFER Matrix (Survey Analysis for Evaluating Risk) to score and communicate risk tied to deficiencies cited during surveys. Each Requirement for Improvement (RFI) is plotted based on:
Likelihood to cause harm, and
Scope (how widespread it is)
The SAFER Matrix, simplified
You can think of it as a grid:
Y-axis (Likelihood to cause harm): Low → Moderate → High (and in some contexts, “Immediate Threat to Life/Health & Safety” is treated as its own urgent category)
X-axis (Scope): Limited → Pattern → Widespread
Here are the practical definitions many teams use when prepping leaders and staff:
Likelihood to cause harm (Y-axis)
Low: harm is rare / unlikely to directly contribute
Moderate: harm could occur in some situations
High: harm could occur at any time
Scope (X-axis)
Limited: a unique occurrence/outlier; not representative of routine practice
Pattern: impacts more than a limited number; process variation
Widespread: pervasive/systemic process failure
Why you should care: As risk increases, findings move toward the upper right (highest risk). Joint Commission explicitly designed this to help organizations prioritize corrective actions toward what matters most.
“We got findings—are we doomed?”
Not at all. Most organizations receive RFIs. The key is what you do next.
After the survey:
Some findings require an Evidence of Standards Compliance (ESC) submission within 60 days (per Joint Commission’s post-survey process).
Certain reports automatically trigger additional review and may lead to Accreditation with Follow-up Survey or Preliminary Denial, depending on decision rules and risk.
If you receive Accreditation with Follow-up Survey, a follow-up survey is required within six months to verify sustained compliance.
How to avoid “failing” Joint Commission in the real world
If you want a practical playbook, focus on the categories most likely to become decision-changing:
Eliminate Immediate Threat risks
Life safety, ligature risks (behavioral health), fire drills, emergency power, medication storage/security, infection prevention basics, environment of care rounds.
Prevent “Widespread” process failures
Any issue that appears across multiple charts/units/shifts quickly becomes pattern/widespread—the scope is what often turns “small” findings into big ones.
Run tracers like surveyors do
Patient record tracers, medication management tracers, infection control tracers, and environment of care tracers—then fix what you find.
Write ESCs that match the SAFER risk
For higher-risk RFIs, treat your response like a mini-CAP: clear root cause, clear fixes, and how you’ll sustain the change. (Joint Commission emphasizes follow-up activity based on risk level.)
Never gamble with documentation integrity
Misrepresentation/falsification is specifically called out as a basis for Preliminary Denial.
Bottom line
You don’t “fail” Joint Commission the way you fail a school exam—but you can land in Preliminary Denial or Denial if there’s an immediate threat, systemic noncompliance, licensing issues, misrepresentation, or unresolved follow-up requirements.