Accreditation Options: Understanding The Joint Commission

The Joint Commission is, by far, the biggest name in hospital accreditation.

Formerly known as the Joint Commission on the Accreditation Healthcare Organizations, TJC's mission is "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." Currently, TJC accredits more than 4,067 general, children's, long-term acute, psychiatric, rehabilitation and specialty hospitals throughout the United States.

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 CMS' Conditions of Participation. However, accreditation by TJC does not mean an organization will not be surveyed by CMS. Like other accrediting bodies, TJC is required to reapply for deemed status on a regular basis, and its current deeming authority for acute-care hospitals extends to 2014. In addition, TJC maintains deemed status for ambulatory healthcare, behavioral healthcare, clinical laboratory services, critical access hospitals, home health, hospitals, nursing care centers and office-based surgery. Disease-specific certification is available in a variety of topics and includes core-level and advanced programs. TJC also provides international accreditation and certification.

The standards
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. In essence, TJC standards are meant to encourage continuous progress toward high-quality and safety in patient care, treatment and services by setting the bar high. Whereas the CMS CoPs are basic requirements designed to ensure that a minimum, fundamental level of safety and quality is achieved, TJC standards reach beyond the CoPs and reward hospitals for attempting to deliver a higher level of service.

TJC standards and National Patient Safety Goals are developed through a thorough process involving consideration of scientific literature and input from healthcare professionals, providers, subject matter experts, consumers, government agencies and employers. New standards and NPSG 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. They 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 NPSG may be revised and again reviewed by the appropriate experts before finally being approved by the Board of Commissioners.

The survey process
 The Joint Commission utilizes 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 elements of performance 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 Jan. 1, 2011, its next survey could take place as early as July 1, 2012, or as late as Jan.1, 2015.

There are 18 over-arching TJC standards that focus on patient safety and quality of care. Each standard is broken down into elements of performance, which are used by TJC surveyors to validate and measure compliance with the quality and safety of patient care, treatment and services. During a survey, EPs are scored on a three-point scale (0 = insufficient compliance, 1 = partial compliance, 2 = satisfactory compliance); those scores lead to an overall picture of compliance and, ultimately, an accreditation decision. The accreditation decision process focuses on how critical an issue is to patient care or safety.

At the organization exit conference, the survey team presents a Summary of Survey Findings Report. In this preliminary report, organizations do not receive an accreditation decision or any scores. Rather, the final accreditation decision is made after TJC receives and approves the hospital's submitted Evidence of Standards Compliance for any Requirements for Improvement identified during the survey. As of January 1, 2013, TJC's accreditation decision categories are as follows:

•    Preliminary accreditation
•    Accreditation
•    Accreditation with follow-up survey
•    Contingent Accreditation
•    Preliminary denial of accreditation
•    Denial of accreditation

TJC accreditation can be 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, NFPA, etc., and evidence-based best practice. Apart from the accreditation survey itself, TJC requires other measures of an organization’s compliance status, most notably an annual Focused Standards Assessment.

The Joint Commission implemented a new Intracycle Monitoring process, which became effective Jan.1, 2013. The underlying premise to this new process, the FSA, is for the organization to conduct a "proactive risk assessment" specific to patient quality and safety to help identify and manage risks. According to TJC, this process replaces and is designed to enhance the former Periodic Performance Review process. Many organizations find 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 new 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), must 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 that 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

Read the other installments of our "Accreditation Options” series, which discuss accreditation as a strategic choice, as well as HFAP, DNVHC (coming soon), and CIHQ accreditation (coming soon).

Sena Blickenstaff has more than 25 years of progressive experience in healthcare leadership and is uniquely equipped to help hospitals achieve compliance with regulatory and accreditation standards and to enhance clinical programs and services and service lines. She previously served as a Joint Commission and CMS deemed-status surveyor, and her close familiarity with the standards along with her collaborative and integrative approach enable her to effectively engage, educate and empower organizations to enhance quality and safety.

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