The Joint Commission’s accreditation process seeks to help organizations identify and correct problems and 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 will begin to implement changes resulting from its Standards Improvement Initiative. As part of SII, the standards and requirements were enhanced based on feedback from health care organizations nationwide. The Joint Commission actively engaged both accredited and non-accredited health care organizations as well as other stakeholders in this improvement project. Extensive comments and suggestions were solicited from the field over the past couple of years. Based on this valuable feedback, the standards were clarified, redundancies were eliminated, and language was rewritten to be more understandable and relevant to the particular health care setting. SII also resulted in the development of electronic standards manuals or E-ditions. The standards manuals and E-ditions include the following additional changes as a result of SII:
- Revised Leadership standards
- Renumbered standards and National Patient Safety Goal requirements
- Revised scoring and accreditation decision process. The scoring emphasis is now on how specific issues directly affect patient health and safety rather than a single count of not-compliant standards. The more critical an issue is to patient care or safety the shorter the time frame that an organization has to address the issue. The result is a process that gives a valid accreditation decision that is more focused on safety and quality and is simple and easily understood.
- New chapters: Emergency Management; Life Safety; Record of Care, Treatment and Services; Transplant Safety; and Waived Testing. Although there are new chapters, there are no new requirements.
For more information about SII, visit http://www.jointcommission.org/Standards/SII/.
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, an organization that is due to have its next unannounced survey in January 2010 could have its survey as early as July 2008 or as late as April 2010 (18 to 39 months). Data from the Priority Focus Process will determine the timing of an organization’s survey within the 18 and 39 month time frame. 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 written summary of the survey findings. In this summary, 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, 2009, 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 secure site on The Joint Commission Connect extranet, or contact their account representative.
11/08