The accreditation process is continuous, data-driven and focuses on operational systems critical to the safety and quality of patient care. Key components of the process are:
- Periodic Performance Review (PPR): A required annual review during which the health care organization evaluates its own compliance with applicable standards and develops a Plan of Action for identified areas of non-compliance. The organization engages in conversation with The Joint Commission to obtain approval of its Plan of Action.
- Tracer methodology: On-site evaluation of standards compliance in relation to the care experience of patients using a “tracer” methodology. Tracer activities permit assessment of operational systems and processes in relation to the actual experiences of selected patients who are under the care of the organization. This activity actively engages all direct caregivers in the accreditation process.
- Priority Focus Process (PFP): An on-site survey focused on patient safety and quality of care at the specific health care organization being surveyed is directed by the PFP. The PFP uses automation to gather pre-survey data from multiple sources including The Joint Commission, the health care organization and other public sources. The PFP then applies rules to 1) identify areas of priority focus relevant standards and appropriate survey activities, and 2) guide the selection of patient tracers.
- Unannounced survey: Unannounced surveys were implemented to enhance the credibility of the accreditation process and to ensure that surveyors observe organization performance under normal circumstances. There are limited exceptions to unannounced surveys, including initial surveys, and accredited organizations can identify up to 10 days each year in which an unannounced survey should be avoided (i.e., black-out dates).
Standards
In October 2006, The Joint Commission launched a Standards Improvement Initiative as part of its continuous effort to improve the standards. The goal of this initiative is to:
- Clarify standards language
- Ensure that standards are program-specific
- Delete redundant or non-essential standards
- Consolidate similar standards
As additional benefits to users, the manuals will be reorganized and the scoring and decision process will be refined. Improvements—both format and language edits—are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs. The 2009 accreditation manuals for these programs will include the improvements from the SII. These 2009 manuals will become available in the fall of 2008. Beginning in 2008, feedback will be sought on standards for the behavioral health care, laboratory and long term care accreditation programs. For more information about SII, visit http://www.jointcommission.org/Standards/SII/.
SII builds on Shared Visions-New Pathways, which involved the substantial consolidation of the standards to reduce the paperwork and documentation burden of the accreditation process and increase its focus on patient safety and health care quality. Joint Commission standards are the basis of an objective evaluation process for health care organizations that can help measure, assess and improve organization performance. The standards focus on important patient, client or resident care and organization functions that are essential to providing quality care in a safe environment. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable. Joint Commission standards are developed with input from health care professionals, providers, measurement experts, consumers and employers. New standards are added only when they will have a direct impact on the quality of care.
Survey process
In 2004, the survey process was substantially modified to be more data-driven and patient-centered thus enhancing its value, relevance and credibility. The survey process focuses on evaluating actual care processes as patients are traced through the care, treatment and services they receive. This “tracer methodology” is guided by the Priority Focus Process and involves visits to care and service areas. In addition, surveyors conduct “systems tracers” to analyze key operational systems that directly impact the quality and safety of patient care. System tracers involve discussion and education about the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, and other current topics of interest to the organization. During the survey, surveyors validate the organization’s implementation and monitoring of the Plan of Action emanating from the PPR and review the environment of care, human resources and credentials.
Accreditation decisions
The accreditation decision process focuses on ongoing standards compliance and is based primarily on the number of standards that are scored not compliant. 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. 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 Evidence of Standards Compliance submission. As of January 1, 2008, the accreditation decision categories are accreditation, provisional accreditation, conditional accreditation, preliminary denial of accreditation, denial of accreditation, and preliminary accreditation. For more information about accreditation decisions, see “Facts about accreditation decisions.”
For more information, visit The Joint Commission website, www.jointcommission.org. Accredited organizations may also visit their secure site on The Joint Commission Connect extranet, or contact their account representative.
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