The Joint Commission’s accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment and services.
Standards
In 2009, The Joint Commission implemented a Robust Process Improvement (RPI) program that allows us to target our own processes that need improvement, and make the changes sustainable. RPI embraces Lean and Six Sigma concepts, engages and energizes all staff, and is led by staff internally trained to be Green Belts and Black Belts as well as change agents. Through RPI, we have focused on various processes, including our accreditation programs. Some of our first RPI projects tackled:
- Improving the standards development process: creating valuable, relevant standards in less time.
- Communicating new standards and other changes more efficiently: ensuring that accredited organizations as well as internal stakeholders get the new information when needed.
- Improving the consistency of standards interpretation: ensuring that our accredited customers receive valuable, consistent guidance and explanation about standards from The Joint Commission.
Survey process
A survey is designed to be individualized to each organization, to be consistent, and to support the organization’s efforts to improve performance. During an accreditation survey, The Joint Commission evaluates an organization’s performance of functions and processes aimed at continuously improving patient outcomes. This assessment is accomplished through evaluating an organization’s compliance with the applicable standards in the manual, based on the following:
- Tracing the care delivered to patients
- Verbal and written information provided to The Joint Commission
- On-site observations and interviews by Joint Commission surveyors
- Documents provided by the organization
Joint Commission surveys are unannounced, with a few exceptions, such as with the Bureau of Prisons or Department of Defense facilities. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. For example, if an organization’s last survey was January 1, 2009, it could have its survey as early as July 1, 2010 or as late as April 1, 2012 (18 to 39 months). For more information, see “Facts about the on-site survey process.”
Accreditation decisions
The accreditation decision process focuses on how critical an issue is to patient care or safety. Compliance with the standards is scored by determining compliance with elements of performance, which are specific performance expectations that must be in place for an organization to provide safe, high quality care, treatment and services. At the organization exit conference, the survey team presents a preliminary Summary of Survey Findings Report. In this report, organizations will not receive an accreditation decision or any scores. The final accreditation decision will be made after The Joint Commission receives and approves an organization’s Evidence of Standards Compliance submission. As of January 1, 2010, the accreditation decision categories are Accreditation, Provisional Accreditation, Conditional Accreditation, Preliminary Denial of Accreditation, Denial of Accreditation, and Preliminary Accreditation. For more information, see “Facts about accreditation decisions.”
Expectations of accreditation
An organization’s accreditation cycle is continuous, as long as the organization has a full, unannounced survey within 39 months of its last survey, and continues to meet all accreditation-related requirements, including, but not limited to, submission of an annual periodic performance review, and an annual subscription payment. The PPR is an additional requirement of the accreditation process in which an organization reviews its compliance with all applicable Joint Commission standards and completes and submits to the Joint Commission a plan of action for any standard not in full compliance. The plan of action also includes Measures of Success. The PPR facilitates a continuous accreditation process by incorporating an additional form of evaluation.
For more information, visit The Joint Commission Web site, www.jointcommission.org. Accredited organizations may also visit their Joint Commission Connect extranet site, or contact their account representative.