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Facts about The Joint Commission Accreditation Standards

January 12, 2021

The Joint Commission, also known as TJC, is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world.Founded in 1951, it accredits and certifies healthcare organizations based on quality in patient safety and process improvement. Its stated mission and vision are headlined by the theme, “Lead the way to zero harm.”

Accreditation is given to hospitals, home care service organizations, nursing care centers, behavioral health care services, ambulatory care centers and practices, and laboratory services. Certifications are given for type of care such as cardiac, stroke, palliative, ortho, blood management, among others.

The Joint Commission created accreditation and certification standards to help organizations measure, assess, and improve performance. These standards set expectations for patient care and organizational functions. The Joint Commission is a nationally-recognized leader in performance measurement. By achieving this level of accreditation, organizations signal to the public, payers, and affiliations that they have achieved a high level of care and that they can be trusted to carry out professional standards in their work.

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.

A healthcare organization must renew its accreditation with TJC every 36 months and laboratories must renew accreditation every 24 months to stay current with this quality standard and certification. It is industry best practice to maintain these high standards of quality of care within your organization.

Standards Development Process

The Joint Commission uses expert advice to determine when new standards should be added. The Commission 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 lists 8 steps from the standards development process, including:

  1. Evidence of a need to address quality and safety issues through new or modified requirements. These issues are identified by scientific literature or by standing committees, advisory groups, accredited organizations, professional associations, or other groups associated with the Joint Commission.
  2. Preparation of standards in draft form with input from medical experts, advisory panels, focus groups, and other stakeholders.
  3. National dissemination 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. Revision, review, and approval of the standards by executive leadership.
  5. Enhancement of the survey process to include new standards requirements and administration of survey testing.
  6. Training of surveyors on compliance assessment using the new standards.
  7. Publication of new standards for use by healthcare professionals.
  8. Evaluation of new standards’ effectiveness through feedback for ongoing improvement.

How Primary Source Verification Helps Entities Meet Joint Commission Standards

The Joint Commission requires that hospitals and other healthcare entities conduct Primary Source Verification when verifying the credentials of a provider. This means that if a job description requires a license, certification, or registration, the healthcare entity that employs the individual must verify that the practitioner’s qualifications are current and valid. The verification must be performed by confirming the validity of the documentation either directly from the original source or an authorized agent of that source.

This can be done by one of the following approved methods: direct correspondence, documented telephone conversation, secure electronic verification from the source, or reports from qualified credentials verification organizations. Copies of documents do not meet Joint Commission requirements.

Conducting primary source verification for all your providers can be a complex and time-consuming process. Hiring an accredited and certified credentials verification organization (CVO) can streamline and assure the authenticity of primary sources. 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 entities throughout the nation. Learn about how Verified License Search and Status® by Verisys is a real-time transaction engine that 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 providers from licensing boards in all U.S. states, jurisdictions, and territories across every healthcare taxonomy.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
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