Accreditation Process Overview | Joint Commission
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Accreditation Process Overview

April 27, 2016

The Joint Commission’s accreditation process seeks to help organizations identify and resolve problems, and to inspire them to improve the safety and quality of care, treatment, and services.

Standards
Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable. The standards are published electronically in the E-dition® and in hard copy manuals by Joint Commission Resources (JCR), the official publisher and educator of The Joint Commission.

Survey process
Joint Commission surveys are unannounced, with some exceptions, such as initial surveys. A survey is designed to be individualized to each organization, to be consistent, and to support the organization’s efforts to improve performance. During the on-site survey, Joint Commission surveyors evaluate an organization’s performance of functions and processes aimed at continuously improving patient outcomes. They do this by:

  • Tracing the care delivered to patients, residents or individuals served
  • Reviewing information and documentation provided by the organization
  • Observing and interviewing staff and, if appropriate, patients

Accreditation decisions
The scoring and decision process is based on an evaluation of compliance with Joint Commission standards and other requirements. Compliance with the standards is scored according to specific performance expectations called elements of performance. While a preliminary Summary of Survey Findings Report is provided at the conclusion of the on-site survey, this report does not include an accreditation decision. The final accreditation decision is made at a later date, after the report is reviewed by Joint Commission Central Office staff. The accreditation decisions that can be awarded are: Preliminary Accreditation, Accreditation, Accreditation with Follow-up Survey, Contingent Accreditation, Preliminary Denial of Accreditation, and Denial of Accreditation.

Expectations of accreditation
An organization’s accreditation cycle is continuous, as long as the organization has a full, unannounced survey within 36 months of its last survey, and continues to meet all accreditation-related requirements, including, but not limited to, submission of an annual Intracycle Monitoring (ICM) profile and the Focused Standards Assessment (FSA). The ICM process facilitates a continuous accreditation process by incorporating an additional form of evaluation that is conducted in between full accreditation surveys. 
 
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