The scoring and decision process is based on the criticality of the standards and other requirements regarding their relationship to the quality and safety of patient care. The Joint Commission strives to ensure that standards compliance scoring and the accreditation decisions are:
- Reflective of an organization’s performance with respect to Joint Commission standards and elements of performance (EPs).
- Transparent – all components of the process are fully disclosed to accredited and certified organizations.
- Easily understood by all involved parties.
- Based on the premise that some standards are “critical,” or more directly impact the patient than others.
Elements of performance are the performance expectations for determining if a standard is in compliance. EPs are scored on a three-point scale:
0 = insufficient compliance
1 = partial compliance
2 = satisfactory compliance
All partially compliant or insufficiently compliant EPs must be addressed via the Evidence of Standards Compliance (ESC) submission process. The time line for completing the ESC submission depends on the “criticality” of findings and immediacy of risk, and is due either within 45 or 60 days.
At the organization exit conference, the survey team presents a preliminary Summary of Survey Findings Report. In this report, organizations will not receive an accreditation decision or any scores. The final accreditation decision will be made subsequently. The following is an overview of the accreditation decisions. Specific information about accreditation decisions, policies and procedures can be found in The Joint Commission’s accreditation manuals. The accreditation decisions are:
Preliminary Accreditation results when a health care organization demonstrates compliance with selected standards used in the surveys conducted under the Early Survey Policy.
Accreditation is awarded to a health care organization that is in compliance with all applicable standards at the time of the on-site survey or has successfully addressed all Requirements for Improvement (RFIs) in an ESC submission within 45 or 60 days following the posting of the Accreditation Survey Findings Report and does not meet any other rules for other accreditation decisions.
Accreditation with Follow-up Survey is recommended when a health care organization is not in compliance with specific standards that require a follow-up survey within 30 days to six months. The organization also must successfully address the identified problem area(s) in an ESC submission.
Contingent Accreditation results when a health care organization has successfully abated an immediate threat to life situation through direct observation or other method; fails to successfully address all requirements of the Accreditation with Follow-up Survey decision; shows some evidence of engaging in possible fraud or abuse; demonstrates patterns or trends of noncompliance at an initial survey; and/or is not recommended for certification by the Centers for Medicare & Medicaid Services (CMS) after undergoing its first Joint Commission survey to initially achieve Medicare certification or recognition. In most cases, a follow-up survey in 30 days will be required to show resolution of the issues that led to the decision. If an organization receives this decision because it was not recommended for certification by CMS or demonstrates systemic patterns or trends of noncompliance at an initial survey, the organization will remain in Contingent Accreditation until it can be recommended for certification or it meets a rule for Preliminary Denial of Accreditation or Denial of Accreditation.
Preliminary Denial of Accreditation is recommended when there is justification to deny accreditation to a health care organization as evidenced by one or more of the following: an immediate threat to health or safety to patients or the public; submission of falsified documents or misrepresented information; lack of a required license or similar issue at the time of survey; failure to resolve the requirements of a Contingent Accreditation status; or significant noncompliance with Joint Commission standards. This decision is subject to review and appeal by the organization before the determination to deny accreditation.
Denial of Accreditation results when a health care organization has been denied accreditation as a result of not permitting the performance of any survey by The Joint commission; failing to resolve an Accreditation with Follow-up Survey or Contingent Accreditation status; failing to pay survey or annual fees; or failing to submit an ESC or measure of success (MOS). All review and appeal opportunities have been exhausted.