Healthcare QM

Cassandra Booe
Joint Commission

The Joint Commission is an independent, not-for-profit organization that accredits and

certifies more than 21,000 health care organizations and programs in the United States. These
organizations include hospitals and healthcare organizations that provide ambulatory and officebased surgery, behavioral health, home health care, laboratory, and nursing care center services.
The Joint Commissions primary focus is to determine if organizations seeking accreditation are
continually monitoring and improving the quality of care they provide.
Currently, the Joint Commission performs unscheduled surveys of healthcare
organizations which means that surveyors can show up at any time during a predefined window
of opportunity. Surveys for accredited health care organizations occur once every 3 years (two
years for laboratories) to ensure that the accredited organizations are in compliance with all
standards. Accreditation through the Joint Commission does not consist of only one on-site
survey every three years, but is actually a continuous process. This survey cycle includes a
midpoint self-assessment which consists of the organization evaluating itself against applicable
standards as well as submission of a written progress report to the Joint Commission.
Organizations who are accredited by the Joint Commission will have their quality reports
published by the Commission on its website, Quality Check. This allows consumers to review
the organizations performance on implementing National Patient Safety Goals (NPSGs) and
meeting core measures. The website also allows consumers to see the health care organizations
accreditation history.
The Joint Commissions on-site survey process utilizes a tracer methodology which
consists of using information from the organization itself in order to follow the experience of
care, treatment, and services for a number of patients through the organizations entire health
care delivery process. This allows for performance issues to be identified and system processes

Healthcare QM
Cassandra Booe
Joint Commission

corrected. There are three different types of tracers used by the Joint Commission: individual
tracer activity; system tracer activity; and accreditation program-specific tracers. Individual
tracer activity consists of surveyors tracking actual patients within the organization in order to
provide more information on the experiences and care received by those patients. System tracer
activity consists of relevant staff members being surveyed in order for surveyors to evaluate
systems, processes, and the coordination of communication among different staff and
departments that are involved in certain processes. Finally, accreditation program-specific tracers
are used to identify risk points and safety concerns within the different departments for types of
care, treatment, and services.
Being accredited through the Joint Commission means that the accredited health care
organization qualifies for deemed status. Deemed status means that the Centers for Medicare &
Medicaid Services (CMS) assumes that the organization meets the Conditions of Participation if
it is currently accredited by one of the approved accrediting organizations. This is important
because in order for a health care organization to receive payment for services rendered to
Medicare and Medicaid patients, the organization must meet the government requirements for
program participation, including the Conditions of Participation.
Once the on-site survey has been completed, the surveyors report the probable
accreditation decision of the Joint Commission based on the survey findings. There are five
categories used by the Joint Commission to report its decision: Accredited; Accreditation with
follow-up survey; Contingent accreditation; Preliminary denial of accreditation; and denial of
accreditation. Accredited status means that the organization has shown compliance with all
applicable standards at the time of the on-site survey or addressed all requirement for
improvements (RFIs) within 45 or 60 days following the posting of the survey findings.

Healthcare QM
Cassandra Booe
Joint Commission

Accreditation with follow-up survey means that the organization was not in compliance with
certain standards and will have to undergo another survey within 30 days to 6 months to followup in order to ensure compliance with all standards. Contingent accreditation is given when the
organization did not meet all of the Joint Commissions standards at the time of the on-site
survey as well as having RFIs that were in excess of the published levels for that year.
Organizations with this status may appeal, however they will have to show compliance with
standards and may also be subject to a follow-up survey in 30 days. An accreditation decision of
preliminary denial of accreditation means that the organization is significantly below compliance
standards in multiple performance areas, with RFIs in excess of the published levels for that year.
Organizations may appeal this decision by presenting additional information or evidence of
compliance prior to the accreditation denial. Finally, denial of accreditation means that all appeal
procedures have been exhausted and the organization has been denied accreditation through the
Joint Commission.
Accreditation by the Joint Commission is desirable by health care organizations because
it shows consumers that performance standards are being met. As can be seen by everything
mentioned above, becoming accredited through the Joint Commission is not a quick and easy
process for any organization. Obtaining accreditation through this organization is a public
accomplishment that demonstrates a health care organizations commitment to patient care.

Healthcare QM
Cassandra Booe
Joint Commission

Resources:

The Joint Commission. (2016). Facts about Federal Deemed Status and State Recognition.
Retrieved from:
https://www.jointcommission.org/facts_about_federal_deemed_status_and_state_recognition/

The Joint Commission. (2016). Facts about the Tracer Methodology. Retrieved from:
https://www.jointcommission.org/facts_about_the_tracer_methodology/

The Joint Commission. (2016). Joint Commission FAQ Page. Retrieved from:
https://www.jointcommission.org/about/jointcommissionfaqs.aspx

Shaw, P. & Carter, D. (2015). Quality and Performance Improvement in Healthcare. AHIMA
Press Publications. Chicago, IL.