Joint Commission Fact Sheets
June 17, 2009

Facts about the Public Information Policy

The Public Information Policy applies to all organizations that have an accreditation history with The Joint Commission. The Joint Commission is committed to making relevant and accurate information about health care organizations available to interested parties. Information regarding a health care organization’s quality and safety of care helps organizations improve their services. This information may also help educate consumers and health care purchasers in making informed choices about health care. At the same time, it is important that confidentiality be maintained for certain information to encourage candor in the accreditation process. The Joint Commission’s primary vehicles for providing this information publicly are Quality Check® and Quality Reports.

Quality Check® and Quality Reports

Quality Check is The Joint Commission’s Web site for making available descriptive and performance information about accredited and non-accredited organizations. Quality Reports are publicly available and include relevant and useful information about the quality and safety of care provided in individual Joint Commission-accredited organizations. Quality Reports are created at the organization level, and contain information regarding an organization’s accreditation status, its compliance with National Patient Safety Goals, and performance measurement results, as appropriate. Joint Commission Quality Reports for each accredited organization include the following information:

  • The date of the most recent full on-site survey
  • The accreditation decision based on the most recent full on-site survey
  • The organization’s current accreditation decision. If an organization has been denied accreditation, this information will be posted on Quality Check for one year.
  • The date of the most recent on-site evaluation of the organization, if not a full survey
  • Standards areas with requirements for improvement (RFIs), if the organization has a decision of provisional accreditation, conditional accreditation, or preliminary denial of accreditation or has been denied accreditation
  • Subsequent satisfaction of RFIs and the date(s) of resolution for specific standards areas
  • Subsequent new RFIs and the date(s) assigned
  • Services included in the accreditation survey
  • Joint Commission policies or rules that lead to provisional accreditation, conditional accreditation, preliminary denial of accreditation, or denial of accreditation
  • Disease-specific care certification(s) and the effective date of each certification
  • The receipt of special quality recognition awards, as recognized by the Board of Commissioners (for example, the Ernest Amory Codman Award, Magnet status)
  • Compiance with National Patient Safety Goal requirements
  • Performance against National Quality Improvement Goals
  • Performance in relation to Patient Experience of Care Measures, as data becomes available

Each accredited organization is afforded the opportunity to prepare a commentary of up to two pages regarding its Quality Report. The commentary accompanies any organization Quality Reports distributed by The Joint Commission, whether via hard copy or The Joint Commission Web site. Each Quality Report released by The Joint Commission will also include appropriate background information. When performance measurement data are included in Quality Reports, such data must be accompanied by information regarding their source of derivation; accuracy, reliability, and validity; appropriate uses; and limitations and potential misses. An organization’s Quality Report may be obtained via the Customer Service Department or through Quality Check. 

Information about health care organizations not accredited by The Joint Commission

For organizations not accredited by The Joint Commission, the following information will be provided on Quality Check:

  • The organization’s name and location
  • The primary services provided by the organization
  • If the organization is accredited by another accrediting body, the name of that accrediting body

Health care organizations not accredited by The Joint Commission will be responsible for maintaining the currency and accuracy of information about them.

Information that is publicly disclosed on request

In addition to information provided in Quality Reports, the following information may be obtained by writing or calling The Joint Commission:

  • The organization’s accreditation history
  • Survey fees paid by an accredited organization
  • The organization’s scheduled survey date(s) once the organization has been surveyed
  • Applicable standards used for an accreditation survey
  • For a tailored survey, the organizational component(s) contributing to a conditional accreditation or denial of accreditation decision
  • RFIs for which The Joint Commission had no or insufficient evidence of resolution when an organization withdrew from accreditation
  • The standards areas for which The Joint Commission had no or insufficient evidence of resolution of RFIs when an organization withdrew from accreditation
  • As applicable, confirmation of the occurrence of a sentinel event at an accredited organization and The Joint Commission’s intent to apply its Sentinel Event Policy to that occurrence


Release of complaint-related information on request

The Joint Commission addresses all complaints that pertain to patient safety or quality of care issues within the scope of Joint Commission standards. Complaints may be forwarded by the Centers for Medicare & Medicaid Services or other federal or state agencies having oversight responsibilities for health care organizations, or may be received directly from consumers, payers or health care professionals. As used here, the term “complaint” includes potentially relevant reports that are received from federal or state agencies, identified in the media, or otherwise obtained by The Joint Commission. The Joint Commission has a toll-free hotline to provide patients, their families, caregivers, and others with an opportunity to share concerns regarding quality of care issues at accredited health care organizations. The toll-free number is (800) 994-6610 and is available 24 hours a day, seven days a week; however, staff members are available to answer calls only on weekdays between 8:30 a.m. and 5:00 p.m. Central Standard Time.

Upon request from any party, The Joint Commission releases the following aggregate information related to complaints about an accredited organization for the three-year period prior to receipt of the request:

  • The number of standards-related written complaints filed against an accredited organization that has met criteria for review
  • If the inquirer submitted or knows about a specific complaint, the applicable standards areas involved in a specific complaint review
  • If the inquirer submitted or knows about a specific complaint, the standards for which RFIs were issued as a result of a specific complaint review
  • If the inquirer is not seeking information in relation to a specific complaint, a summary of the standards areas that were the focus of the complaint evaluation activities
  • If the inquirer is not seeking information in relation to a specific complaint, a summary of the standards areas for which RFIs were issued as a result of complaint evaluation activities
  • When an unannounced or unscheduled survey is based on information derived from a complaint or public sources, the standards areas related to the complaint

The Joint Commission also provides the following information as appropriate, to complainants regarding their complaints:

  • Any determination that the complaint is not related to Joint Commission standards
  • If the complaint is related to standards, the course of action to be taken regarding the complaint, including the specific standards that will be evaluated
  • Whether The Joint Commission has decided to take action regarding an organization’s accreditation decision following completion of the complaint investigation. If The Joint Commission has decided to take no action, the complainant is to be so advised. If The Joint Commission has taken action, the complainant is to be advised in conformance with the guidelines for release of complaint information as set forth above.
  • Any change in an organization’s accreditation decision following completion of the complaint investigation, including the specific standards that were the subject of RFIs.


Release of aggregate performance data

The Joint Commission reserves the right to publish or release aggregate performance data; however, no case-identifiable or protected health information is ever made publicly available. Performance data displayed on Quality Check are available to any interested party at no cost. Performance data on Quality Check may be downloaded electronically in a series of predefined report formats through a linked webpage called “Quality Data.”

Data release to government agencies and organizations with which The Joint Commission performs coordinated survey activities

The Joint Commission makes available to federal, state, local or other government certification or licensing agencies, and to organizations with which The Joint Commission performs survey activities, specific accreditation-related information under the following circumstances:  when The Joint Commission identifies a serious situation in an organization that may jeopardize the health or safety of patients or the public and immediately takes action to deny accreditation; and, upon request, when the request involves otherwise publicly available information.

Additional information is made available when an organization is certified for participation in a federal or state program or licensed to operate by a state agency on the basis of its accreditation. In addition, The Joint Commission may make available information to organizations with which The Joint Commission performs coordinated survey activities. The Joint Commission so advises the organization’s chief executive officer and provides timely notice to local, state, and federal authorities having jurisdiction. The information available to government agencies and organizations with which The Joint Commission performs coordinated survey activities includes the following:

  • The official accreditation decision and any subsequent change in this decision or any designation, such as accreditation watch.
  • Complaint information requested by CMS or state agencies in accordance with deemed status or other recognition requirements, including the following: 
    • Actual complaint if the allegation(s) results in the classification of the complaint as high priority and the governmental entity or organization with which The Joint Commission conducts a coordinated survey has entered into a written information-sharing agreement
    • Action taken on the complaint
    • The standards area(s) in which RFIs were issued as a result of the complaint evaluation
    • The status of the case
  • Specific information when an organization is assigned a conditional accreditation, preliminary denial of accreditation or denial of accreditation decision. This includes the following:  All final RFIs; a statement, if any, from the organization regarding its views on the validity of Joint Commission survey findings; and a copy of the approved plan of correction and the results of the plan of correction follow-up survey.
  • Notification of upcoming full surveys and retrospective dates of other surveys conducted, such as random unannounced or for-cause, only if the governmental agency enters into an information-sharing agreement with The Joint Commission and agrees to maintain the confidentiality of the unannounced survey dates.
  • A copy of the official Accreditation Decision Report for CMS, upon request respecting deemed status determinations, and for state agencies that have entered into specific information-sharing agreements that permit provider-authorized release of such reports to the state agency.
  • The Joint Commission will report to CMS or the Office of the Inspector General in the event that credible evidence of potential fraud or criminal or civil law violation has been identified, and upon notice to the health care organization.


Data release to cooperative accrediting bodies

The Joint Commission makes available to accrediting bodies with which it has formal cooperative agreements relevant portions of Official Accreditation Decision Reports and complaint-related information that are pertinent to the accrediting activities of the cooperative partner. Judgments as to pertinence are made solely by The Joint Commission.

The Joint Commission right to clarify

The Joint Commission reserves the right to clarify information, even if the information involved would otherwise be considered confidential, when an organization disseminates inaccurate information regarding its accreditation.

Confidential information

The Joint Commission keeps confidential the following information received or developed during the accreditation process:

  • The Official Accreditation Decision Report unless its submission is required by a government agency (see the “Data release to government agencies” section); is required by organizations with which The Joint Commission performs coordinating surveys; or is requested by an accrediting body with which The Joint Commission has a formal agreement (see the “Data release to cooperative accrediting bodies” section.)
  • Information learned from the organization before, during, or following the accreditation survey, which is used to determine compliance with specific accreditation standards
  • An organization’s root cause analysis prepared in response to a sentinel event or in response to other circumstances specified by The Joint Commission
  • All other materials that may contribute to the accreditation decision (for example, medical records, surveyor notes)
  • Written staff analyses and Accreditation Committee minutes and agenda materials
  • The algorithms used in the Priority Focus Process
  • The Priority Focus Process information used in an organization’s survey, other than that provided to the organization’s staff prior to survey
  • An organization’s self-assessment and related Plan(s) of Action
  • The identity of any individual who files a complaint about an accredited organization, except when the complaint is shared by The Joint Commission with a governmental entity, an organization with which The Joint Commission performs coordinated surveys, or accrediting organizations with which The Joint Commission has formal complaint-sharing agreements and the receiving organization has agreed to maintain the confidentiality of the complainant. In instances in which the receiving organization cannot assure the confidentiality of the complainant, any complainant-identifying information shall be redacted by The Joint Commission prior to sharing.