Joint Commission Fact Sheets

Facts about Scoring and Accreditation Decisions
In January 1, 2004, as part of its Shared Visions-New Pathways initiative, The Joint Commission changed its scoring and accreditation decision process. The Joint Commission’s previous accreditation decision process was a score-based system that encouraged organizations to “ramp up” to do well on a survey to achieve a high score. The current accreditation decision process:
  • Focuses on ongoing standards compliance.
  • Is more credible, assuring the public that accredited organizations have demonstrated full compliance with the standards.
  • Is based primarily on the number of standards that are scored not compliant. 
  • Simplifies the compliance screening process in determining an accreditation decision.
  • Focuses less on “scores” and more on using the standards to achieve and maintain excellent operational systems.   

Elements of Performance

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. EPs are scored on a three-point scale:  0 = insufficient compliance, 1 = partial compliance, 2 = satisfactory compliance. Each standard has one or more EP. Each EP is labeled in the accreditation manuals and EPs all have the same weight. EPs are divided into three scoring categories:
  • “A” Elements of Performance usually relate to structural requirements (for example, policies or plans) that either exist or do not exist, and are scored either 0 or 2. “A” EPs may also address an issue that must be fully compliant even though it focuses on performance or outcome (e.g., National Patient Safety Goals). “A” EPs may also be related to a Condition of Participation that must always be fully compliant. 
  • “B” Elements of Performance relate to the presence or absence of requirements and are usually answered yes or no. If the organization does not meet the requirements, the EP is scored 0. If the organization meets the requirements, but there is concern about the quality or comprehensiveness of the effort, the surveyor will review the applicable principles of good process design with the organization. If the applicable principles are met, the EP is scored 2. If none of the principles are met, the EP is scored 0. If more than one, but not all of the principles are met, the EP is scored 1.
  • “C” Elements of Performance are frequency-based EPs and are scored based on the number of times an organization does not meet a particular EP. A “C” EP is scored 2 if there are one or fewer occurrences of noncompliance; it is scored 1 if there are two occurrences of noncompliance; and it is scored 0 if there are three or more occurrences of noncompliance.   
After an organization’s compliance with an EP is scored, its track record is evaluated as noted below.  The track record illustrates the amount of time that an organization has been compliant with an EP. This can affect the EP score.
 

Score

2

1

0

Initial Survey

4 months or more

2 to 3 months

Fewer than 2 months

Full Survey

12 months or more

6 to 11 months

Fewer than 6 months

 
 
EPs are then aggregated to determine standards compliance. Standards are scored on a non-numeric two-point scale (compliant or not compliant). More information on the scoring rules is included in the accreditation manuals.  

Compliant and Not Compliant Standards

If a single EP is scored 0 (insufficient compliance), it automatically triggers a not compliant standard. However, if a single EP is scored 1 (partial compliance), it does not trigger a not compliant standard; 35 percent or more of the EPs under a specific standard would have to be scored 1 (partially compliant) for that standard to be considered not compliant. If standards are scored not compliant at the time of the on-site survey, an organization must demonstrate that it has corrected systems and processes to be in compliance with those standards by submitting Evidence of Standards Compliance. Organizations have 45 days to submit an ESC to The Joint Commission. Also, if required by the EP, the organization will also submit an indicator, or Measures of Success, that it will use to assess sustained compliance over time. Four months after approval of the ESC, the organization will submit data on its Measure of Success to demonstrate sustained compliance over time.
 
After the on-site survey, organizations do not receive an overall score or grid element score, and no scores are shared with the health care organization. The final accreditation decision will be made after The Joint Commission receives and approves an organization’s ESC submission and its Measures of Success (when required). However, surveyors will leave an accreditation report on-site. The report includes:
  • Requirements for Improvement by priority focus area (processes, systems or structures important to providing safe quality care in a health care organization).
  • The standard number, the text of the standard, the specific findings of the survey team and the EPs that are partially compliant or insufficiently compliant. The organization must address all Requirements for Improvement, in the form of ESC, to be accredited.
  • Supplemental findings of EPs that were scored partially compliant but did not cause the standard to be scored not compliant. Supplemental findings do not require an ESC to be submitted. 

Accreditation decision categories

  • Accredited ― The organization demonstrates compliance with all of the standards at the time of the on-site survey, or it resolves Requirements for Improvement via an acceptable ESC submission.
  • Provisional Accreditation ― All Requirements for Improvement have not been addressed in the ESC submission, or the organization has failed to achieve an appropriate level of sustained compliance as determined by a Measure of Success result (when required). 
  • Conditional Accreditation ― Number of standards scored not compliant is between two and three standard deviations above the mean number of not compliant standards for organizations in that accreditation program. The organization must undergo an on-site follow-up survey.
  • Preliminary Denial of Accreditation ― Number of standards scored not compliant is three or more standard deviations above the mean number of not compliant standards for organizations in that accreditation program. There is justification to deny accreditation, but the decision is subject to appeal.
  • Denial of Accreditation ― The organization has been denied accreditation, and all review and appeal opportunities have been exhausted.
  • Preliminary Accreditation ― The organization demonstrates compliance with selected standards in the first of two surveys conducted under the Early Survey Policy Option 1. This decision remains in effect until one of the other official accreditation decision categories is assigned, based on a complete survey against all applicable standards approximately six months later.
For more information, accredited organizations may visit their secure site on The Joint Commission Connect extranet, or contact their account representative.

11/06