At the organization exit conference, the survey team presents a preliminary Summary of Survey Findings Report. In this report, organizations will not receive an accreditation decision or any scores. The final accreditation decision will be made subsequently. The following is an overview of the accreditation decisions. Specific information about accreditation decisions, policies and procedures can be found in The Joint Commission’s accreditation manuals. The accreditation decisions are:
Accreditation is awarded to a health care organization that is in compliance with all applicable standards at the time of the on-site survey or has successfully addressed all Requirements for Improvement (RFIs) in an Evidence of Standards Compliance (ESC) submission within 60 days following the posting of the Accreditation Survey Findings Report and does not meet any other rules for other accreditation decisions.
Accreditation with Follow-up Survey results when a health care organization is in compliance with all standards, as determined by an acceptable ESC submission. A follow-up survey is required within six months to assess sustained compliance.
Limited Accreditation results when a health care organization is in satisfactory compliance with the limited set of standards and elements of performance (EPs) assessed in the first of the two surveys conducted under the Early Survey Policy.
Preliminary Denial of Accreditation is recommended when there is justification to deny accreditation to a health care organization as evidenced by one or more of the following: an immediate threat to health or safety to patients or the public; submission of falsified documents or misrepresented information; lack of a required license or similar issue at the time of survey; failure to resolve the requirements of an Accreditation with Follow-up Survey status; or significant noncompliance with Joint Commission standards. This decision is subject to review and appeal by the organization before the determination to deny accreditation.
Denial of Accreditation results when a health care organization has been denied accreditation. All review and appeal opportunities have been exhausted. For an organization undergoing an initial survey, the organization has failed to demonstrate compliance with all applicable Joint Commission standards.
The decision process for all certification programs has only two possible outcomes:
Certified programs meet all the requirements for their particular program. They either received no RFI or successfully addressed any RFIs through an ESC submission involving either clarifications or evidence of corrections for the review findings.
Not Certified programs are those that: apply for certification and – recognizing during their on-site review that they would not meet the requirements – requested that the review be changed to an education visit; or, failed to meet the requirements and did not have their review converted to an education visit. Programs that fail to meet the requirements will have to address any RFIs and submit an acceptable ESC.
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.
Read more about accreditation and certification decisions