Eligibility for Hospital Accreditation | Joint Commission
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Sunday 1:06 CST, January 21, 2018

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Eligibility for Hospital Accreditation

January 15, 2015
  1. The organization is in the United States or its territories, or if outside the United States, is operated by the U.S. government or under a charter of the U.S. Congress.

  2. If required by law (for all programs), the organization has a facility license or registration to conduct its scope of services.

  3. The organization can demonstrate that it continually assesses and improves the quality of its care, treatment, and/or services.  This process includes a review by clinicians, including those knowledgeable in the type of care, treatment, and/or services provided at the organization.

  4. The organization identifies the services it provides, indicating which care, treatment, and/or services it provides directly, under contract, or through some other arrangement.

  5. The organization provides services that can be evaluated by Joint Commission standards.

  6. If the organization uses its Joint Commission accreditation for deemed status purposes, the organization meets the Center for Medicare and Medicaid Services (CMS) definition of a hospital as set forth in “Appendix A:  Medicare Requirements for Hospitals” (AXA); see “Appendix B:  Special Conditions of Participation for Psychiatric Hospitals” (AXB) for information about psychiatric hospitals that use accreditation for deemed status purposes.

  7. The organization meets parameters for the minimum number of in patients/volume of services required for organizations seeking Joint Commission accreditation for the first time; that is 10 inpatients served, with one active at the time of survey.  A hospital that is seeking Medicare Certification and is new to The Joint Commission must have one active inpatient case at the time of survey.

    • If the hospital’s Average Daily Census is 21 or more, or if the hospital is a specialty hospital (cardiac, orthopedic, or surgical), the hospital must be able to provide inpatient records for at least 10 percent of the ADC, but not less than 30 inpatient records at the time of survey.

    • If the hospital’s Average Daily Census is less than 21 (1-20), the hospital must be able to provide 20 inpatient records.

  8. The tests, treatments, or interventions provided at the organization are prescribed or ordered by a licensed independent practitioner in accordance with state and federal requirements.

Eligibility Requirements for Initial Surveys

For hospitals new to the accreditation process or undergoing an initial survey for deemed status purposes, surveyors must be able to review records equal to 10% of the average daily census but not fewer than 30 inpatient records, or for small hospitals not fewer than 20 inpatient records.  Surveyors will review a minimum of 30 inpatients records in a specialty hospital (such as a cardiac, orthopedic, or surgical hospital) regardless of average daily census.  For hospitals not using Joint Commission accreditation for deemed status purposes, a minimum 10 inpatients must be served, with one in active treatment at the time of survey.