The Accreditation Committee of The Joint Commission's Board of Commissioners oversees the accreditation decision process to ensure its accuracy and validity. The Committee also establishes and monitors the application of all policies and procedures regarding the accreditation and certification decision process. The Committee is composed of 10 board members and has eight scheduled meetings.
Approximately 6,600 accreditation decisions are rendered annually, and approximately 4 percent are referred to the Accreditation Committee for direct review and determination. Decisions are referred to the committee under various circumstances that include, but are not limited to, the following:
- If, after survey, the organization is found to meet the rules for Preliminary Denial of Accreditation or Conditional Accreditation.
- If The Joint Commission president determines to preliminarily deny accreditation based on identification of a condition that poses a serious threat to patient care or safety.
When the Accreditation Committee determines that an organization may be denied accreditation, the organization is placed on Preliminary Denial of Accreditation—a decision that is subject to public release. The health care organization has the right to request a review of the decision before a decision to deny accreditation is rendered. The organization has five business days to request a review.
During these five days and throughout the review process, the organization retains the Preliminary Denial of Accreditation status. A decision to deny accreditation is rendered if the organization allows five days to elapse without submitting a request for review, or if the organization abandons its request for review at any point in the process.
Review Hearing Panel
If an organization decides to request a review of the Preliminary Denial of Accreditation decision, a hearing is scheduled before a Review Hearing Panel. The panel is composed of a member of the Accreditation Committee and two individuals who have knowledge about or experience with the type of services involved in the Preliminary Denial of Accreditation decision. The surveyor(s) who conducted the survey will be present at the hearing, if available.
An organization must submit materials to be considered by a Review Hearing Panel, including any materials specifically requested by The Joint Commission, at least 10 days before the scheduled hearing date. At least 30 calendar days before the scheduled hearing date, The Joint Commission will send the organization written notice of the time and place of the hearing and any additional materials related to the Preliminary Denial of Accreditation decision.
At the hearing before the Review Hearing Panel, the organization may be accompanied by legal counsel. The organization may make oral and written presentations. Only information about the organization’s activities and performance at the time of the organization’s survey is considered relevant to the deliberations by the Review Hearing Panel. Thus, the panel will not ordinarily consider information presented at the hearing concerning actions taken subsequent to the survey upon which the Preliminary Denial of Accreditation decision was based. The Accreditation Committee member who served on the panel presents the panel’s report to the Accreditation Committee. The organization will be furnished a copy of the panel’s report and may submit comments on it.
After consideration of the panel’s report, and any comments from the organization, the Accreditation Committee may decide to award Accreditation, Provisional Accreditation or Conditional Accreditation, or deny accreditation to the organization.
If the Accreditation Committee decides to deny accreditation, the organization may appeal to the Board Appeal Review Committee and may submit its arguments—whether procedural or substantive—in writing to the Committee.
Board Appeal Review Committee
The Board Appeal Review Committee is composed of five members of the Board of Commissioners who were not involved in the original accreditation decision. The Accreditation Committee member who served on the Review Hearing Panel attends the Board Appeal Review Committee meeting to present and respond to questions about the Review Hearing Panel report. The Accreditation Committee member does not participate in the deliberations or vote of the Board Appeal Review Committee. Representatives of the organization do not attend the meeting.
After review of the decision of the Accreditation Committee that considered the Review Hearing panel's report, the organization’s comments on the panel’s report, and the organization's written submission to the Committee, the Board Appeal Review Committee issues The Joint Commission’s final accreditation decision.
For more information, call The Joint Commission, (630) 792-5800, or visit The Joint Commission Web site.
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