The scoring and decision process for certification is based on the criticality of the standards and other requirements related to the quality and safety of patient care. The Joint Commission strives to ensure that standards compliance scoring and the certification decisions are:
- Reflective of an organization’s performance with respect to Joint Commission standards and elements of performance (EP).
- 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.
EPs 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 timeline for completing the ESC submission depends on the “criticality” of findings and immediacy of risk.
- EPs that have a direct impact on patient, individual served or resident care require submission of an ESC within 45 days.
- EPs that have an indirect impact on patient, individual served or resident care require an ESC within 60 days.
Certified programs meet all the requirements for their particular program. They either:
- Received no Requirements for Improvement (RFI).
- Successfully addressed the RFIs through an ESC submission that involved either clarifications or evidence of corrections for the review findings.
Note: Although the results of a certification program’s decision have no effect on an organization’s accreditation status, a potential Immediate Threat to Health or Safety situation discovered during a certification review may trigger a for-cause accreditation survey of the larger organization that could affect its accreditation status.