Facts about The Joint Commission Accreditation Standards

Jun 16, 2021 | Credentialing, Monitoring, Verification

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The Joint Commission, also known as TJC, accredits and certifies more than 22,000 healthcare organizations and services in the United States. TJC accreditation sets a standard for patient safety and process improvement. Most US state governments will not reimburse Medicare and Medicaid services without Joint Commission accreditation, so successful TJC accreditation is essential for any healthcare entity accepting payment from government programs.

Founded in 1951, TJC (formerly known as JCAHO), accredits and certifies healthcare organizations to ensure they meet quality standards. It envisions a future where TJC is “leading the way to zero,” meaning zero harm in healthcare.

Accreditation is given to organizations such as hospitals, home care service organizations, nursing care centers, behavioral health care services, ambulatory care centers and practices, and laboratory services. Certifications are given to healthcare services such as cardiac, stroke, palliative, and blood management. States where the Joint Commission is not recognized for state licensure, such as Oklahoma, Pennsylvania, and Wisconsin, use their own alternative assessment procedures. In California, The Joint Commission uses a joint survey process in cooperation with state authorities.

The Joint Commission created accreditation and certification standards to help organizations measure, assess, and improve performance. The Joint Commission’s accreditation sets a standard of care that determines if an organization meets an acceptable level of care. When organizations achieve accreditation, they establish trust with the public, payers, and other affiliated organizations that recognize high professional standards.

To become accredited by The Joint Commission, healthcare entities must demonstrate that they are competent in patient care and professional requirements. Although there may be some differences in how these standards are administered across different healthcare settings (hospitals have different standards than pharmacies and nursing homes, for example), TJC expects high levels of competency across all types of healthcare entities.

Healthcare organizations must renew their accreditation with TJC every 36 months and laboratories must renew accreditation every 24 months. Organizations are expected to maintain these high standards of quality of care throughout the entire three-year accreditation period. In other words, organizations should consistently follow these standards to maintain their accreditation.

TJC History

The organization currently known as The Joint Commission credits Ernest Codman, MD, for founding the ideals that would eventually lead to its formation. Codman proposed an “end result system of hospital standardization” in 1910, with the aim of tracking patients to determine whether or not their treatments were effective. In 1913, Codman’s colleague founded the American College of Surgeons (ACS) with an end-result objective. Four years later, ACS developed a one-page Minimum Standard for Hospitals. When ACS began on-site inspections the following year, only 89 of 692 hospitals met those requirements.

In 1951, ACS joined with the American College of Physicians, American Hospital Association, American Medical Association, and Canadian Medical Association and created the Joint Commission on Accreditation of Hospitals (JCAH). In 1953, JCAH began offering accreditation to hospitals.

Congress passed a provision in 1965 that JCAHO-accredited hospitals were eligible for Medicare and Medicaid participation. In 1987 JCAH changed its name to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Joint Commission International (JCI) was formed in 1994 by Quality Healthcare Resources, Inc., and JCAHO to accredit medical services around the world. Responding to concerns that announced visits might allow healthcare organizations to falsely represent themselves, JCAHO initiated unannounced surveys and reviews in 1996. JCAHO implemented its first set of National Patient Safety Goals in 2003, which are still used today. In 2007, JCAHO changed its name to The Joint Commission.

Standards Development Process

The Joint Commission uses expert advice to determine when new standards should be added. TJC reviews scientific literature and consults with healthcare professionals, government agencies, subject matter experts, providers, and consumers before considering a new standard. New standards must relate to patient safety or care, improve health outcomes, meet or surpass healthcare laws and regulations, and be measurable. The Board of Commissions is required to review new standards.

The Joint Commission follows these 8 steps in their standards development process:

  1. An emerging need to address quality and safety issues through new or modified requirements. These issues are identified through scientific literature or discussions with committees, groups, organizations, or associations aligned with The Joint Commission.
  2. Preparation of drafts of new standards using input from medical experts, advisory panels, focus groups, and other stakeholders.
  3. National distribution and review of the draft standards. The public may comment on the standards on the Standards Field Review page of The Joint Commission website.
  4. Review and approval of the standards by executive leadership.
  5. Enhancement of the survey process to include new standards requirements.
  6. Education of surveyors on how to assess compliance using the new standards.
  7. Publication of new standards for use by healthcare professionals.
  8. Collection of feedback on new standards’ effectiveness for ongoing improvement.

How Primary Source Verification Helps Entities Meet Joint Commission Standards

The Joint Commission requires hospitals and other healthcare entities to conduct Primary Source Verification when verifying the credentials of a provider. The validity of the documentation such as licenses or certifications must be confirmed either directly from the original source or an authorized agent of that source. This can be done through direct correspondence, documented telephone conversation, secure electronic verification from the source, or reports from qualified credentials verification organizations.

Primary source verification must be completed regularly for all your providers. This process can be lengthy and complex and can require using financial and personnel resources that might be better utilized elsewhere. When you hire an accredited and certified credentials verification organization (CVO), you can streamline the process. Delegating primary source verification will meet Joint Commission requirements, save you time, and protect your patients.

As a credentials verification organization, Verisys provides primary source verification for healthcare providers and entities throughout the nation. Learn about how Verified License Search and Status® by Verisys protects patients from incompetent providers and protects organizations from fines and reputational loss by actively acquiring, verifying, aggregating, and continuously monitoring primary source data on healthcare provider licenses from licensing boards in all U.S. states, jurisdictions, and territories for all taxonomies.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
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