Spinal Surgery Programs | Joint Commission
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Friday 5:10 CST, April 20, 2018

Spinal Surgery Programs

Certification Matters Newsletter

Certification Contact Directory

Patrick Phelan
Executive Director
(630) 792-5145

David Eickemeyer
Associate Director

Caroline Isbey
Associate Director

Zachary George
Associate Director

Francine Topps
Business Development Specialist

Loren Rohal
Associate Director


Spinal Surgery programs (discectomy, laminectomy, and spinal fusion) are certified under the standards for Disease-Specific Care programs, The standards are not specific to spinal surgery, but are a general framework for a well-run disease-management program.

Certification process

Certification requirements for spinal surgery programs address three areas:

  • Compliance with consensus-based national standards.

  • Effective and consistent use of appropriate, evidence-based clinical practice guidelines for the discectomy, laminectomy, and spinal fusion patient populations.

  • Collection and analysis of a minimum of four performance measures specific to the spinal surgery patient population (a minimum of two performance measures must be clinical in nature.)

Spinal surgery programs that successfully demonstrate compliance in all three areas are awarded certification for a two-year period. At the end of the first year, the organization is required to attest to its continued compliance with standards and provide evidence of performance improvement activities. To maintain certification, the cycle repeats with an on-site review conducted every two years and a bi-annual submission of an acceptable assessment of compliance by the organization.

Unique Details About Certification for Spinal Surgery

Certification for Spinal Surgery encompasses three distinct procedures. To be certified under this title, an organization must conduct all three of these procedures: discectomy, laminectomy, and spinal fusion.

Although this certification recognizes three surgical procedures, it is considered one certification review, and is charged as one disease program.

To apply for this certification, the organization does not need to specify all of the areas of the spine where these procedures are performed (i.e., discectomy: cervical, anterior, posterior, etc.). The organization just needs to identify that it does at least one type of the procedure.

Because this is considered one certification, only four performance measures are required. These measures do not have to be shared across all three surgical procedures.

Even if a patient receives two or three of the surgical procedures, the patient’s primary diagnosis is used for data collection purposes.

Benefits of certification

Spinal surgery programs seek certification because it:

  • Demonstrates commitment to a higher standard of service

  • Provides a framework for organizational structure and management

  • Provides a competitive edge in the marketplace

  • Enhances staff recruitment and development

  • Is recognized by insurers and other third parties.