Accreditation options update: Understanding the Joint Commission (TJC)

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This is part 2 of an 8-part series on Hospital Accreditation Options. It was previously published in Becker’s Hospital Review. Compass Clinical Consulting has updated the content to reflect the myriad changes in the Accreditation Options since the previous publication.

The Joint Commission (TJC) is, by far, one of the biggest names in hospital accreditation.

Formerly known for years as the Joint Commission on the Accreditation Healthcare Organizations, TJC's mission still rings true today: "To continuously improve healthcare for the public in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe, effective care of the highest quality and value."

Officially founded in 1951, TJC was granted deeming authority for hospitals through Social Security Amendments enacted in 1965. Organizations accredited by TJC are "deemed" to be in compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs).

However, accreditation by TJC does not mean an organization will not be surveyed by CMS. Like all other accrediting bodies, TJC is required to reapply for deemed status on a regular basis for all of its programs, including acute care hospitals, ambulatory healthcare, behavioral healthcare, clinical laboratory services, critical access hospitals, home health, hospitals, nursing care centers, and office-based surgery. Disease-specific certification is also available in a variety of topics and includes core-level and advanced programs. TJC also provides international accreditation and certification.

The benchmark known as “The Joint Commission’s Gold Seal of Approval” remains a national and international icon representing the most thorough and comprehensively credible set of healthcare standards across the industry.

Accreditation by The Joint Commission is believed to guide hospitals in achieving, maintaining, and demonstrating consistent excellence in healthcare quality and safety, leading to a process that facilitates healthcare organizations to move toward high-reliability achievements and improved patient care, treatment, and service outcomes.

TJC presents its standards as "the basis of an objective evaluation process that can help healthcare organizations measure, assess, and improve performance." The standards target important elements of patient care and functions within an organization's structure that are essential to providing safe, high-quality care.

TJC standards are designed to encourage continuous progress toward high quality and safety in patient care, treatment, and services by setting the bar higher than its competitors, leading quality and safety benchmarks across the country.

Whereas the CMS CoPs are considered the basic requirements to ensure that a minimum, fundamental level of safety and quality is achieved, TJC standards are designed to reach beyond the CoPs and reward hospitals for attempting to deliver a higher level of service, and thus progress toward the goal of high reliability in the healthcare industry.

TJC standards and National Patient Safety Goals (NPSGs) are developed through a rigorous process involving consideration of scientific literature and input from healthcare professionals, providers, subject matter experts, consumers, government agencies, and employers. New standards and NPSGs are added only if they relate to patient safety or quality of care; have a positive impact on health outcomes; and can be accurately measured. The draft standards and NPSGs are then reviewed by TJC's Board of Commissioners and distributed nationally (and posted on the TJC website) for comment from healthcare providers. If necessary, the draft standards and NPSGs may be revised and again reviewed by the appropriate experts before finally being approved by the Board of Commissioners.

The most recent changes to TJC standards and Elements of Performance (EPs) were published and effective as of January 1, 2017. These changes and revisions are a continuation of TJC’s “Project Refresh” which further eliminated standards/elements of performance that were

(1) duplicative,
(2) covered so extensively that they are now considered routine standards of operations or clinical care processes, and
(3) were already adequately addressed by law and regulations. Project Refresh also introduced TJC’s new scoring methodology.

An organization accredited by TJC is responsible for the awareness of and compliance with the standards and EPs. The healthcare organization can access the information through the established program manuals, the Joint Commission Perspectives, and other industry materials.

The following were the most challenging standards for hospitals from 2016:
1. EC.02.06.01 The hospital establishes and maintains a safe, functional environment.
2. IC.02.02.01 The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
3. EC.02.05.01 The hospital manages risks associated with its utility systems.
4. LS.02.01.35 The hospital provides and maintains systems for extinguishing fires.
5. LS.02.01.30 The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

Survey process
The Joint Commission uses a combination of tracer methodology; documentation review; staff, medical staff, and leadership interviews; and additional on-site observation to verify compliance with standards. During an actual TJC survey, surveyors will conduct individual and system tracers to validate compliance with TJC standards (and CMS Conditions of Participation for deemed-status organizations) and individual EPs, and to identify any risks to patient safety and/or quality of care, treatment, and services. Individual tracers follow the experience of care through the entire healthcare process in the organization. System tracers evaluate the integration of related care processes, including coordination of care amongst all disciplines and departments involved in the patient's care, the competency of staff to provide safe, effective and high-quality patient care, and the use of data and performance improvement methodology to enhance and sustain improvement.

For hospitals, TJC surveys are unannounced and can occur between 18 and 36 months after each organization's previous full survey. So, as an example, if a hospital's last survey occurred on January 1, 2017, its next survey could take place as early as July 1, 2018, or as late as January 1, 2020.

At the organization’s exit conference, the survey team presents a Summary of Survey Findings Report. This report will be posted to the organization’s extranet site. Included in this preliminary report is the Survey Analysis for Evaluating Risk™ (SAFER™) matrix, which gives a visual representation of the risk level of each Recommendation for Improvement (RFI). The surveyor’s observations are plotted on the SAFER™ matrix according to the risk level of the finding. According to TJC, risks are defined as the likelihood of the finding to cause harm to patients, staff, and/or visitors (low, moderate, or high) and the scope, or prevalence, at which the RFI was observed (limited, pattern, widespread). The visual scale views the plotting of the findings on the matrix that moves from the bottom left corner (lower risk level) to the upper right corner of the matrix (highest risk level).

More information about TJC’s SAFER™ matrix can be found on the Joint Commission’s website:

Following the exit conference, the organization’s report of findings is posted on the organization’s secure Joint Commission Connect site within 10 business days of the completion of the on-site survey.

As of January 1, 2017, TJC's accreditation decision categories are as follows:
• Accreditation
• Accreditation with Follow-up Survey
• Preliminary Denial of Accreditation
• Denial of Accreditation

Journey to High Reliability
TJC accreditation is considered to encourage a culture of continuous improvement and attention to compliance due to the way it measures adherence to standards, which are based on industry standards of care, such as the CDC, AAMI, WHO, and NFPA, among others, and evidence-based practices.

Apart from the accreditation survey itself, TJC requires other measures of an organization’s compliance status, most notably an annual Focused Standards Assessment (FSA) attestation. The FSA is a management tool designed to assist an accredited organization in reviewing applicable standards for compliance.

In 2013, TJC implemented the Intracycle Monitoring (ICM) process. The underlying premise of this process, the FSA, was for the organization to conduct annual "proactive risk assessments" specific to patient quality and safety to help identify and manage risks. According to TJC, this process replaced and was intended to enhance the former Periodic Performance Review process. Many organizations believe the use of mock tracer activities to be an effective means of managing the proactive risk assessment and coordinating the completion of the FSA process.

Under the FSA process, risk is assessed by probability of harm, severity of harm, proximity to the patient, and potential number of patients at risk. Standards that are identified by the organization as high-risk will be reported on annually. And while all standards and elements of performance can be scored as part of the FSA, TJC only requires that those standards identified as "Risk Standards" (denoted with the R icon in the standards manuals) be scored and a plan of correction developed, with a supporting measure of success if required under the element of performance, to address each non-compliant element of performance.

There are several options for completing the FSA and communicating the process to TJC, which is outlined in the Accreditation Process Chapter of TJC's standards manual. When preparing for the FSA process, organizations should also review TJC's Accreditation Participation Requirements (APR.03.01.01) specific to the FSA for additional elements of performance that must be followed when performing the FSA.

As with most accreditation bodies, the costs associated with TJC accreditation derive primarily from participation fees. Hospitals and other healthcare organizations are charged an annual fee (in January of each participating year) to be part of TJC's accreditation program. Annual fees for hospitals are based on the size and complexity of each individual organization and range significantly. In addition, participating healthcare organizations are billed for the costs associated with surveys.

TJC standards are provided electronically to hospitals free of charge. Accredited organizations can purchase a print copy of the appropriate standards manual, as well as access to the electronic edition of the manual for institutional use.

More information about accreditation by The Joint Commission can be found at

Next in the Accreditation Options series, we explore DNV GL - Healthcare’s National Integrated Accreditation for Healthcare Organizations.

Related articles: Accreditation: A Hospital CEO’s Strategic Choice


Darlene Evans, MSN, RN, CPHQ is a healthcare quality leader with more than 30 years of experience, specializing in clinical and regulatory operations management, accreditation readiness and response, staff training, and strategic business development. With her expertise in CMS, TJC, and HFAP standards and her commitment to education and collaboration, Darlene has a proven track record of leading projects and helping clients identify opportunities for improvement and achieve sustainable, long-term results. As a Principal with Compass Clinical Consulting, Darlene serves as team leader and project coordinator for regulatory and accreditation mock surveys, helping hospitals, health systems, behavioral health facilities, and ambulatory surgery centers prepare for survey.

Twitter: @Compasscc

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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