The Joint Commission (TJC) 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 by evaluating healthcare organizations and inspiring them to excel in providing safe, effective care of the highest quality and value. Currently, TJC accredits and certifies more than 19,000 healthcare organizations and programs 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 the CMS Conditions of Participation. However, accreditation by TJC does not mean an organization will not be surveyed by CMS. TJC is, like other accrediting bodies, required to reapply for deemed status on a regular basis, and its currently deeming authority for acute care hospitals extends to 2014. In addition, TJC maintains deemed status for ambulatory surgery centers, clinical laboratories, critical access hospitals, as well as home health and hospital agencies.

The Standards
TJC bills 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 lofty patient care goals by setting the bar high. Whereas CMS Conditions of Participation (CoPs) are basic requirements designed to ensure that a minimum, fundamental level of safety and quality is achieved, TJC standards reach beyond 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 National Patient Safety Goals 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 National Patient Safety Goals may be revised and again reviewed by the appropriate experts before finally being approved by the Board of Commissioners.

The Survey Process
Whereas CMS surveys are conducted through patient and staff interviews, open and closed medical record reviews, and observations of the environment in which care is delivered, TJC surveys utilize a combination of tracer methodology, documentation review, and additional on-site observation to verify compliance with standards. 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 January 1, 2011, its next survey could take place as early as July 1, 2012, or as late as January 1, 2015.

TJC standards are broken down into elements of performance (EPs), which give surveyors a concrete way to measure compliance. During a survey, each EP is scored; 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, 2011, TJC’s accreditation decision categories are:

• Preliminary Accreditation
• Accreditation
• Accreditation with Follow-up Survey
• Contingent Accreditation
• Preliminary Denial of Accreditation
• Denial of Accreditation

Benefits
Arguably, much of the comparative value of accreditation by The Joint Commission comes from the fact that TJC has the greatest share of the hospital accreditation market. Because TJC accreditation is more common, its significance is better appreciated, and therefore it is sought more widely.TJC accreditation can also be considered to encourage a culture of continuous improvement and attention to compliance, due to the way it measures adherence to standards. Apart from the accreditation survey itself, TJC requires other measures of an organization’s compliance status, most notably an annual periodic performance review (PPR). Hospitals and other healthcare organizations are required to conduct a PPR to determine their continuing compliance with TJC standards. Each organization evaluates is own performance based on Measures of Success that quantify whether or not care and safety goals have been met. As part of its PPR, hospitals must also complete and submit a plan of action to address any standards that are not in full compliance. This additional form of evaluation is intended to encourage hospitals to focus on compliance at least annually, rather than every three years. It is worth noting that, as of January 1, 2012, PPR will be referred to as Focused Standards Assessment. The Focused Standards Assessment will be required annually in non-survey years and is not to be submitted the year of triennial eligibility.

Costs
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 (from just over $2,000 to almost $38,000). In addition, participating healthcare organizations are billed for the costs associated with surveys. In particular, an on-site survey fee covering the direct costs of the survey is billed within five days of the survey’s completion.

TJC standards are provided to hospitals free of charge. Accredited organizations receive a free print copy of the appropriate standards manual, as well as access to the electronic edition of the manual.

Ultimately, TJC accreditation has, in many ways, become the benchmark for other hospital accreditors. Hospitals wishing to demonstrate excellence in care may well turn to TJC as the most recognizable arbiter of hospital quality. More information about accreditation by The Joint Commission can be found at www.jointcommission.org. And you can follow the other installments of our “Accreditation Choices” series, which discuss accreditation as a strategic choice, as well as NIAHO and HFAP accreditation.