Accreditation is awarded to a health care organization that is in compliance with all standards at the time of the onsite survey or has successfully addressed requirements for improvement in an Evidence of Standards Compliance within 45 or 60 days following the posting of the Accreditation Summary Findings Report.
Provisional Accreditation results when a health care organization fails to successfully address all requirements for improvement in an ESC within 45 or 60 days following the posting of the Accreditation Summary Findings Report.
Conditional Accreditation results when a health care organization was previously in Preliminary Denial of Accreditation due to an Immediate Threat to Health or Safety situation; or the organization failed to resolve the requirements of a Provisional Accreditation; or it was not in substantial compliance with the applicable standards, as usually evidenced by a single issue or multiple issues that pose a risk to patient care or safety that was present at the time of survey. The organization must remedy identified problem areas through preparation and submission of Evidence of Standards Compliance and subsequently undergo an onsite, follow-up survey. In addition, an organization may receive Conditional Accreditation for failure to meet certain Joint Commission participation requirements, such as a Periodic Performance Review (PPR) or timely submission of data.
Preliminary Denial of Accreditation results when there is justification to deny accreditation to the organization as evidenced by an Immediate Threat to Health or Safety situation; or the organization failed to resolve the requirements of a Conditional Accreditation, or it was in significant noncompliance with Joint Commission standards. The decision is subject to review and appeal prior to the determination to deny accreditation; the appeal process may also result in a decision other than Denial of Accreditation.
Denial of Accreditation results when a health care organization has been denied accreditation. All review and appeal opportunities have been exhausted.
Preliminary Accreditation results when the health care organization demonstrates compliance with selected standards in the surveys conducted under the Early Survey Policy.
More information about accreditation decisions, policies and procedures can be found in all of The Joint Commission’s accreditation manuals.
11/08