THE JOINT COMMISSION

The Joint Commission

Katherine V. Konnert
UC Clermont College HCMT2010

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The Joint Commission

While fulfilling their vision, that all people experience the safest, highest quality, bestvalue health care across all settings, and supporting their mission and purpose to continuously
improve public healthcare, The Joint Commission has set over 250 regularly updated standards
that address issues like infection control, medication management, patient rights, and data
collection. They offer a voluntary accreditation and certification process to hospitals,
ambulatory, and office-based surgery, behavioral health, and home health care, as well as
laboratory and nursing care. By evaluating healthcare facilities, the JC encourages and enables
them to provide safe and effective healthcare that is of high quality and value (Shaw & Elliott,
2012; The Joint Commission, 2016).
As part of these evaluations, in order to measure compliance with its standards, the JC
conducts surveys at acute care facilities least every 39 months. The certified on-site survey team
is comprised of experienced healthcare practitioners, and their visits are unannounced to
persuade facilities to always be operating at their very best. The on-site survey process utilizes
three types of tracer methodologies, which allow the surveyors to follow and study experiences
throughout the healthcare processes. Individual tracers follow selected patients through their
course of care, while system tracers focus on the specific processes of care. These processes
include data management, infection control, and medication management. Program-specific
tracers concentrate on identifying risk and safety concerns of different types of services (The
Joint Commission, 2016; The Joint Commission, 2016).
When a facility has deemed status, it means that the Centers for Medicare & Medicaid
Services acknowledges that the facility complies with the Conditions of Participation or
Conditions for Coverage. These are requirements that must be met or exceeded in order for the

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facility to receive payment from Medicare and Medicaid programs. Deemed status is obtained
by achieving accreditation through an approved deemed status survey, such as the JCs survey.
When the JC completes its evaluation and reports its decisions on accreditation, it assigns
facilities one of five categories: accredited, accreditation with follow-up survey, contingent
accreditation, preliminary denial accreditation, or denial of accreditation (Shaw & Elliott, 2012;
The Joint Commission, 2015).
If the facility has been awarded accreditation, it complies with the JCs standards, but
must prepare a plan of correction for any cited requirements for improvement, as well as monitor
and report the results. The JC awards a facility accreditation with a follow-up survey if the
facility is not completely in compliance with some specific standards, but is given a chance to
address their issues and demonstrate change through a follow-up survey. Contingent
accreditation is awarded if a facility does not meet all of the JCs standards and has too many
deficiencies. The facility is expected to show improvement and complete follow-up survey. A
preliminary denial of accreditation means a facility has several areas in which they are in
noncompliance with JC standards, along with an excess of deficiencies. The facility may appeal
this denial. If a facility receives a denial of accreditation, then there are no longer any available
appeal procedures (Shaw & Elliott, 2012).
The JC publishes all accreditation decisions in its Quality Reports. The reports are
available to the general public, through a website called, Quality Check, and also include
valuable information about National Patient Safety Goal performance and Hospital National
Quality Improvement Goal performance, as well as special quality awards. As part of its efforts
to improve the quality of public health, The Joint Commission empowers patients to make
informed healthcare decisions. (The Joint Commission, 2016; The Joint Commission, 2016).

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References

Shaw, P., & Elliott, C. (2012). Quality and Performance Improvement in Healthcare (5th ed.).
(C. E. Blondeau, Ed.) Chicago, Illinois, United States: American Health Information
Management Association.
The Joint Commission. (2015, November 18). Facts about federal deemed status and state
recognition. Retrieved from The Joint Commission:
http://www.jointcommission.org/facts_about_federal_deemed_status_and_state_recogniti
on/
The Joint Commission. (2016, January 26). Facts about the tracer methodology. Retrieved from
The Joint Commission:
http://www.jointcommission.org/facts_about_the_tracer_methodology/
The Joint Commission. (2016, April 18). Joint Commission FAQ Page. Retrieved from The Joint
Commission: http://www.jointcommission.org/about/jointcommissionfaqs.aspx
The Joint Commission. (2016). Quality Check. Retrieved from The Joint Commission:
http://www.qualitycheck.org/consumer/searchQCR.aspx
The Joint Commission. (2016). The Joint Commission. Retrieved from
http://www.jointcommission.org/