The Joint Commission has accredited hospitals for more than 50 years and today it accredits approximately 4,250 general, children’s, long term acute, psychiatric, rehabilitation and surgical specialty hospitals, and accredits 358 critical access hospitals maintaining a unique accreditation program for these organizations. Approximately 88 percent of the nation's hospitals are currently accredited by The Joint Commission.
Eligibility
Any health care organization may apply for Joint Commission accreditation under the Hospital Accreditation Standards if all the following requirements are met:
- The organization is in the United States or its territories or, if outside the United States, is operated by the U.S. government, under a charter of the U.S. Congress.
- The organization assesses and improves the quality of its services. This process includes a review of care by clinicians, when appropriate.
- The organization identifies the services it provides, indicating which services it provides directly, under contract, or through some other arrangement.
- The organization provides services addressed by the Joint Commission’s standards.
Benefits of accreditation
Hospitals seek Joint Commission accreditation because it:
- Strengthens community confidence in the quality and safety of care, treatment and services.
- Provides a competitive edge in the marketplace.
- Improves risk management and risk reduction.
- Helps organize and strengthen patient safety efforts.
- Provides education on good practices to improve business operations.
- Provides professional advice and counsel, enhancing staff education.
- Provides a customized, intensive process of review grounded in the unique mission and values of the organization.
- Enhances staff recruitment and development.
- Provides deeming authority for Medicare certification.
- Recognized by insurers and other third parties.
- May reduce liability insurance costs.
- Provides a framework for organizational structure and management.
- May fulfill regulatory requirements in select states.
Standards
Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment. The Joint Commission develops its standards in consultation with health care experts, providers and researchers, as well as measurement experts, purchasers and consumers. For 2009, the standards-based performance areas for hospitals are:
- Environment of Care
- Emergency Management
- Human Resources
- Infection Prevention and Control
- Information Management
- Leadership
- Life Safety
- Medication Management
- Medical Staff
- National Patient Safety Goals
- Nursing
- Provision of Care, Treatment, and Services
- Performance Improvement
- Record of Care, Treatment, and Services
- Rights and Responsibilities of the Individual
- Transplant Safety
- Waived Testing
Survey process
To earn and maintain accreditation, a hospital must undergo an on-site survey by a Joint Commission survey team. Joint Commission surveys are unannounced and occur 18 to 39 months after the previous unannounced survey. The objective of the survey is not only to evaluate the hospital, but to provide education and guidance that will help staff continue to improve the hospital's performance. The survey process evaluates actual care processes by tracing patients through the care, treatment and services they received. It also analyzes key operational systems that directly impact the quality and safety of patient care. The survey team can include one or more health care professionals, including a physician, nurse, life safety code specialist, or hospital administrator who has senior management level experience. The Joint Commission has a cadre of more than 400 surveyors, reviewers and life safety code specialists who are trained and certified, and receive continuing education on advances in quality-related performance evaluation.
Performance measurement requirements
The Joint Commission’s ORYX® initiative integrates outcomes and other performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts. In 2002, accredited hospitals began collecting data on standardized—or “core”—performance measures. In 2004, The Joint Commission and the Centers for Medicare & Medicaid Services began working together to align measures common to both organizations. These standardized common measures, called “Hospital Quality Measures,” are integral to improving the quality of care provided to hospital patients and bringing value to stakeholders by focusing on the actual results of care. Measure alignment benefits hospitals by making it easier and less costly to collect and report data because the same data set can be used to satisfy both CMS and Joint Commission requirements.
Hospital information available to the public
Information about the safety and quality of accredited hospitals is available to the public at Quality Check®, www.qualitycheck.org. This comprehensive listing includes each accredited hospital’s name, address, telephone number, accreditation decision, current accreditation status and effective date, and its Quality Report. Quality Reports include detailed information about a hospital’s performance and how it compares to similar hospitals.
Cost of accreditation
Annual fees are based on the size and the service complexity of individual hospitals and range from $1,780 to $36,845. For 2009, the on-site survey fees for hospitals are: $2,500 per surveyor for the first day and $1,030 per surveyor for the second and subsequent days. For small hospitals (those with fewer than 26 beds and less than 50,000 visits), the 2009 annual fee is $1,090 and the on-site survey fees are $4,580 per survey. The on-site survey fee is paid at the beginning of the year in which the on-site survey will be conducted, along with the annual fee, and covers survey-related direct costs. Organizations have the option to receive a corporate orientation or corporate summation. These can be conducted by the entire survey team, by the team leader only, or by Central Office staff. The Joint Commission extranet includes a fee calculator to help estimate annual subscription billing costs. For more information about pricing, including a weighted volume worksheet for annual fees, contact The Joint Commission’s Pricing Unit at pricingunit@jointcommission.org or (630) 792-5115.
For more information
For questions about standards, contact the Standards Interpretation Group at standards@jointcommission.org or (630) 792-5900. For questions about hospital accreditation services, call (630) 792-3007. Corporate offices for systems of accredited organizations (i.e. multi-hospital systems in all states) should call (630) 792-5778.