Accreditation Process Overview | Joint Commission
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Accreditation Process Overview

August 7, 2017

The Joint Commission’s accreditation process seeks to help organizations identify risks to quality and patient safety — including risk previously unknown to the organization — by conducting a meaningful assessment, and to inspire them to improve their care, treatment and services. 

Joint Commission standards are the basis of this objective evaluation process that can help health care organizations assess, measure 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 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, 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.  

Read more about the accreditation process

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