General FAQs
Standards FAQs
Survey Process FAQs
Long Term Acute Care and Surgical Hospital FAQs
- Can a surgical hospital or a long term acute care hospital be accredited by the Joint Commission?
- I am a surgical hospital, am I required to have an emergency department, intensive care unit, pharmacy, radiology, and a laboratory?
- I am a long term acute care hospital, am I required to have an emergency department, intensive care unit, pharmacy, radiology, and a laboratory?
General FAQs
The following chart shows the differences between accreditation and licensure/certification:
|
|
Accreditation Surveys |
State Surveys |
|
Purpose |
Performance improvement; deemed status in some states |
licensure and/or Medicare/Medicaid provider certification |
|
Oversight |
private, not-for profit company |
governmental entity |
|
Compliance |
voluntary |
mandatory |
|
Emphasis |
evaluation |
inspection |
|
Frequency |
triennial |
annual |
|
Funding |
provider fees |
tax dollars |
|
Focus |
What is the organization doing right? How can it improve? |
What is the organization doing wrong? |
|
Expectations |
achievable standards |
minimum expectations |
|
Scoring |
systems and processes |
individual deficiencies |
|
Value |
improvement |
enforcement |
|
Process |
survey to standards |
survey to regulations |
|
Approach |
education/consultation |
sanctions/penalties/fines |
|
Findings |
recommendations for improvement |
citations |
|
Award |
accreditation |
licensure or certification |
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With our online Quality Check™, you can "check up" on the performance of health care facilities, by reviewing their latest Quality Report.
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You can complete our online Quality Incident Report Form. For more information, please call 800-994-6610.
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Standards FAQs
Please check our the Standards FAQs section of our website. If you don't find your answer there, you can complete our Online Standards Form or call 630-792-5900.
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Survey Process FAQs
Your organization can normally be surveyed within three to four months after we receive your application. However, the key issue is whether you are ready to be surveyed. We will evaluate the past four months of service for compliance with the standards. If your organization is beginning to prepare for survey at the time of application, it should request to be surveyed at least four to six months later. Your application for survey is valid for 12 months from the date it is submitted. You may request a specific month for your survey and we will try to accommodate you.
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This varies considerably from organization to organization and depends on the amount of time and resources available to prepare for survey. Most organizations take one full year from the point of the initial decision to the actual survey date.
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You must be in compliance for four months on an initial survey, twelve months on a resurvey. We don't expect a track record of compliance for a preliminary accreditation survey (early survey option one).
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This varies with the number of surveys conducted in the previous month but averages about 15 days. Your organization is retroactively accredited to the day after survey, but you may not market your accreditation until you receive the final award letter.
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We do not automatically transfer accreditation to new owners who acquire an accredited health care organization. Accreditation will not continue if significant changes occur to the circumstances existing at the time of the previous survey. An accredited organization must notify us no more than 30 days after it merges, is acquired, or undergoes any major change in services, location, capacity, or corporate structure. We will extend accreditation until we can determine if a special survey is necessary. Failure to notify us of ownership and service changes can result in a loss of accreditation.
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Contact the Customer Service Center toll free at 877-223-6866. You can view a catalog of all our publications online at www.jcrinc.com.
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If your system owns or operates at least two hospitals, you may be able to use the multihospital survey option.
However, if your hospitals do not each have their own medical staffs and unique patient populations, we may survey you under health care network standards. A hospital network offers a continuum of care and will refer patients to the most appropriate facility. If several of your hospitals draw from the same geographic population (sending cardiac cases to one hospital, pediatrics to another, for example), you may be a network.
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We survey physician groups as part of the hospital if they are organizationally and functionally integrated with the hospital, or if the hospital publicly represents the group as part of its organization.
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The Joint Commission surveys most hospitals every three years. In the final 12 months of this cycle, a hospital may spend considerable time, effort, and money to get ready for the survey. The hospital looks closely at its performance improvement efforts and measures the results to find out if they meet survey requirements. Once the survey is over, the hospital may return to "business as usual" and may reduce its focus on performance improvement.
Hospitals that participate in continuous accreditation efforts monitor and improve their performance every day, not just in preparation for a survey. At any point in the accreditation cycle, these hospitals know if their performance efforts are working. Continuous improvement efforts help hospitals maintain the highest quality of patient care and services. In addition, hospitals can use their resources more wisely, avoiding the high cost of gearing up for a Joint Commission survey.
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Long Term Acute Care and Surgical Hospital FAQs
Yes, they would be accredited using the hospital accreditation manual.
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No, your organization is not required to have these essential services if you are a surgical hospital. If your organization provides these services via a contract, then only the contract would be evaluated at the time of survey.
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No, your organization is not required to have these essential services if you are a long term acute care hospital. If your organization provides these services via a contract, then only the contract would be evaluated at the time of survey.
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