The standards of the Joint Commission are a foundation for an objective evaluation process the may help healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key for providing safe high quality care services. The Joint Commission’s standards set goal expectations of reasonable, achievable and surveyable performance of an organization. Only new standards that are relative to patient safety or care quality, have positive impact on healthcare outcomes, and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develop these standards.
The survey process is designed to be unique to each organization, consistent, and supportive of the organizations attempts to improve healthcare performance. During the survey, the Joint Commission evaluates the performance of processes aimed to improve patient outcomes. The assessment is done by evaluating an organizations compliance with standards in the manual based on the following key functions:
Tracing care that is delivered to patients
Verbal and/or written information given to the Joint Commission
Visual observations and interviews performed by the Joint Commission surveyors
Documents provided by the organizations
“Joint Commission surveys are unannounced, with a few exceptions, such as with the Bureau of Prisons or Department of Defense facilities. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. For example, if an organization’s last survey was January 1, 2009, it could have its survey as early as July 1, 2010 or as late as April 1, 2012 (18 to 39 months).”
The decision process focuses on the severity of an issue related to patient care and safety. Compliance with the standards is scored by determining the compliance with performance that needs to be in place for the safety and quality of care within an organization. The survey team will present a preliminary Summary of Survey findings Report at the exit conference. In that report, the organization does not receive scores or decisions. The final decision is made after the Joint Commission receives and approves the organizations Evidence of Standards Compliance submission. The decision categories for accreditation as of January 2011 are as follows:
Accreditation with Follow-up Survey
Contingent Accreditation, Preliminary Denial of Accreditation
Denial of Accreditation
“An organization’s accreditation cycle is continuous, as long as the organization has a full, unannounced survey within 39 months of its last survey, and continues to meet all accreditation-related requirements, including, but...