Facts about The Joint Commission Accreditation Standards

Written by Researchbite | Updated on: February 18, 2023

Facts about The Joint Commission Accreditation Standards

The Joint Commission (TJC) assesses additional elements that can impact patient safety and care to prevent medical mistakes and noncompliance in healthcare organizations. Let us read further about their standards and practices.


Multitasking, interruptions, worker tiredness, communication problems, and other elements fall under this category. TJC selects people to complete the survey regarding their hospital stay when they visit hospitals between 18 and 36 months after their previous hospital survey. The TJC tracks performance benchmarks and outcome metrics through surveys. TJC often makes its appearance known at the beginning of the week and shows up the day after the announcement. As a result, because healthcare institutions must constantly prepare for the visit, the visits are regarded as unannounced. Hospitals operating with financial assistance from the state and federal governments in the form of Medicare and Medicaid payers must hold TJC accreditation to secure liability insurance.

TJC has developed specific standards and quality measures to hold healthcare organizations responsible for public safety in a standardized format. These standards are based on the reported adverse events by organizations that may or may not have harmed patients, such as medication errors, surgical errors, and provider miscommunication. Health-related population-focused similarities like patients with congestive heart failure who frequently require readmission and patients who develop pressure ulcers while receiving hospital care serve as the foundation for quality indicators.

What Is The Joint Commission On Accreditation Of Healthcare Organizations (JCAHO)?

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a nonprofit 501(c) organization with headquarters in the United States that recognizes and accredits more than 22,000 healthcare institutions and initiatives around the country. Nursing homes and other long-term care facilities, behavioral healthcare organizations and addiction services, ambulatory care providers, group practices and office-based surgery practices, independent or free clinics, and psychiatric, pediatric, rehabilitation, and critical access hospitals are among the categories of institutions that The Joint Commission accredits.

The American College of Surgeons (ACS) started working to establish guidelines for hospital procedures in 1910. The American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association all ran hospital standards programs combined in 1951 by the Joint Commission on Accreditation of Hospitals. The Joint Commission on Accreditation of Healthcare Organizations was established in 1987, replacing the Joint Commission on Accreditation of Hospitals (JCAHO). JCAHO had a significant rebranding initiative in 2007 and is now referred to as The Joint Commission, or TJC. In 2021, the Joint Commission marked its 70th birthday. It is the largest and oldest organization in healthcare that sets standards and awards accreditation.

"To constantly improve health care for the public, in conjunction with other stakeholders, by assessing health care organizations and encouraging them to excel in delivering safe and effective care of the greatest quality and value," reads the mission statement of the Joint Commission. The Joint Commission establishes patient safety standards every year, which are the broad principles they will combine with their operational standards during their on-site evaluations. The following are a few of the Patient Safety Goals:

  • Make sure to appropriately identify patients by using two approaches to ensure they receive the required treatments.
  • First, enhance employee communication and ensure the right person receives essential information on time.
  • Use drugs responsibly and confirm that all patient medication information is current.
  • Please ensure the alarms connected to medical equipment are loud and handled right away when they go off.
  • Use the hand-washing instructions from the Centers for Disease Control and Prevention to maintain the safest environment possible.
  • Identify patient safety hazards to lower the suicide risk.
  • For example, ensure the proper operation is conducted on the right patient in the right body area to avoid surgical errors.

Joint Commission Accreditation Benefits

  1. Aids in planning and enhancing patient safety initiatives - The Joint Commission prioritizes patient safety and care quality in its standards and programs.
  2. Increases public trust in the safety and quality of medical care and services - Accreditation sends a clear message about an organization's commitment to providing services of the highest caliber.
  3. Gives a firm a competitive edge in the market - In a cutthroat climate for health care, accreditation may provide a business with a marketing edge and make it easier to win new clients.
  4. Enhances risk minimization and management - the risk of mistake or poor-quality treatment by focusing on cutting-edge performance improvement techniques; Joint Commission standards assist healthcare organizations in consistently improving the safety and quality of care.
  5. Lower the cost of liability insurance - By improving risk management initiatives, certification may widen access to and lower the price of liability insurance protection.
  6. Improves corporate operations via education — Joint Commission Resources, a not-for-profit subsidiary of the Joint Commission, offers accredited companies ongoing assistance and educational services in various contexts.
  7. Offers qualified guidance and recommendations, boosting employee education. The surveyors for the Joint Commission are skilled medical experts who have been educated to offer knowledgeable counsel and educational services during the on-site inspection.
  8. Offers a tailored, in-depth evaluation; Joint Commission surveyors are chosen from various healthcare sectors and placed in organizations that correspond to their experience. Each survey applies to your sector because the requirements are also unique to each accrediting program.

What Exactly are JCAHO Standards?

The Joint Commission establishes guidelines for all divisions inside the organization they are inspecting. The metrics used to evaluate each department's performance regarding the overarching objective of enhanced patient safety and health outcomes are the JCAHO standards. Medical and support departments' policies and procedures are set using these principles by healthcare organizations.

The standards are multi-part measurements that include all of the crucial actions required to have a good result in terms of your health. Each standard has a mix of the following procedures or components:

  • Care plans
  • Procedures
  • Staffing
  • Equipment maintenance
  • Cleaning
  • Uniforms, to name a few.

Only some organizations that JCAHO accredits are required to follow the same set of guidelines. The benchmarks used to assess each operation's efficacy are particular to the objectives specified for that kind of organization. For example, the requirements for a standalone ambulatory surgical facility and a home healthcare business differ. The surveyed entity has a set of criteria for each department. All clinical areas in hospitals being examined have benchmarks against which they are evaluated. Additionally, operational standards are included in every supporting department.

An example list of resources for the surveyed, which is not all-inclusive, is as follows:

  • The Environment of Care includes requirements for building safety, cleanliness,
  • Protection from hospital-acquired infections is part of infection control.
  • Human resources cover personnel policies and processes.
  • Quality improvement is included in performance improvement.
  • The medical staff explains the credentials of professionals.

The Joint Commission releases a print or digital version of its most recent standards every year. They currently have around 250 standards. The Joint Commission's staff develops the standards with input from consumers, regulatory bodies, subject matter experts, and healthcare professionals when necessary. Before being put into practice, new standards must first have the Board of Commissioners of the Joint Commission's approval. Only quantifiable new requirements that have a demonstrable positive impact on patient safety and health outcomes are introduced to the system.

Clinical Relevance Of The Joint Commission-Accredited

TJC offers accreditation to hospitals and other healthcare institutions to assist them in building their reputation. Every two to three years, these healthcare organizations are evaluated. Organizations gain certification if they adhere to all the requirements. To meet the TJC, firms must otherwise create plans of action to enhance safety and quality. A facility must pay TJC a fee to be accredited by the organization. The findings can be made public if they have obtained a passing grade. A charge of around $46,000 is required each year to maintain certification. The certification is necessary to show compliance with and dedication to patient safety. To assess hospitals' adherence to safety, TJC uses a tracer approach. Through individual tracer activity, system tracer activity, and accrediting program-specific tracers, the on-site survey procedure seeks to pinpoint performance problems in hospitals.

  1. Individual: Following a patient's experiences as they get medical attention at a hospital, use the facility's treatments, and use its services during their care.
  2. System: Involves following a patient's experiences while receiving treatment at a hospital with an emphasis on care coordination, communication, departmental procedures, infection control standards, and medication administration.
  3. Program-specific: Analyzing the risk and safety issues associated with a particular program inside a company that offers a specific service or treatment and may have high-risk or many patient groups.

Process For Developing Standards

The Joint Commission consults with experts to decide whether to introduce new standards. Before deciding on a new standard, TJC evaluates the scientific literature and talks with healthcare professionals, governmental organizations, subject matter experts, providers, and consumers. New standards must be quantifiable, enhance health outcomes, meet or exceed healthcare laws and regulations, and be related to patient safety or care. Therefore, new standards must be examined by the Board of Commissions.

The Joint Commission uses three processes while creating standards:

  1. A growing demand for additional or altered criteria to address quality and safety problems. Scientific research or conversations with committees, groups, organizations, or associations affiliated with The Joint Commission are used to identify these problems.
  2. Draughts of new standards are prepared with feedback from stakeholders such as advisory committees, focus groups, and medical professionals.
  3. Review and dissemination of the proposed standards across the nation. On The Joint Commission website's Standards Field Review page, the public may offer feedback on the standards.
  4. The criteria are examined and approved by executive leadership.
  5. The improvement of the survey procedure to incorporate new needs for standards.
  6. Surveyors are being instructed on how to evaluate compliance using the new criteria.
  7. Publication of updated guidelines for use by medical specialists.
  8. Gathering opinions on the success of the new standards to continue to improve.


When confirming a provider's credentials, the Joint Commission mandates that hospitals and other healthcare organizations perform Primary Source Verification. It is necessary to verify the legitimacy of the supporting paperwork, such as licenses or certificates, either directly from the source or through an authorized representative of that source. Direct communication, a recorded phone call, secure electronic verification from the source, or reports from accredited credentials verification agencies can all be used. All of your suppliers must undergo frequent primary source verification. There may be other uses for the financial and human resources needed for this procedure, which can be time-consuming and complex. You can speed up the procedure with a qualified and accredited credentials verification organization (CVO). Primary source verification delegation will satisfy Joint Commission standards, save time, and safeguard your patients.


  • https://www.healthcare-management-degree.net/faq/how-do-healthcare-facilities-maintain-compliance-with-jcaho/



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