Certification is awarded after a review to a health care program or service that is in compliance with all standards, uses clinical practice guidelines (applicable to Disease-Specific Care Certification programs only), and meets performance measurement requirements and certification participation requirements at the time of the on-site review; or, if it has not been place in Conditional or Preliminary Denial of Certification status, has successfully addressed all requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 days following the review. If the program or service does not meet these requirements for certification, it will receive one of the following decisions.
Provisional Certification results when a health care program or service fails to do one or more of the following: 1) Successfully address all requirements for improvement in an ESC within 45 days following the review or in a Measures of Success submission. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 31 days of the due date(s).*
Conditional Certification results when a health care program or service fails to do one or both of the following: 1) Be in substantial compliance with the standards, usually determined by the number of not compliant standards that exceed established thresholds at the time of review. The program or service must remedy identified problem areas through preparation and submission of ESC or Measures of Success and a conditional follow-up review. 2) Meet all requirements for the timely submission of data and information to The Joint Commission within 61 days of the due date(s).*
Preliminary Denial of Certification results when there is justification to deny certification to the health care program or service as usually determined by the number of not compliant standards that exceed established thresholds at the time of review. The decision is subject to appeal prior to the determination to deny certification; the appeal process may also result in a decision other than Denial of Certification.
Denial of Certification results when the organization chooses not to appeal or the appeal of a Preliminary Denial of Certification decision is rejected; or a health care program or service does not permit the performance of any review by The Joint Commission; or the program or service fails to do one or more of the following: 1) Meet requirements for the timely submission of data and information to The Joint Commission within 91 days of the due date(s).* 2) Resolve a Conditional Certification status prior to withdrawing from the certification process. 3) Submit payment for review fees or annual fees.
* Data and information that is expected to be submitted on a timely basis to The Joint Commission include but are not limited to the certification contract, annual updates to the health care program or service’s application for certification, and annual intra-cycle evaluation.
More information about certification decisions, policies and procedures can be found in all of The Joint Commission’s certification manuals.
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