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The Joint Commission

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The joint Commission evaluates and accredits more than 15,000 healthcare organizations and programs in the United States. The Joint Commission is an independent, not-for-profit organization that sets the standards and accrediting body for the nation since 1951. They maintain standards focused on improving the quality and safety of care provided by health care organizations.

Joint Commission accreditation can be earned by many healthcare facilities. These include hospitals, doctor’s offices, nursing homes, office based surgery centers, behavioral health treatment centers, and home care providers. The Joint Commission also awards Disease Specific Care Certification to health plans, disease management service companies, hospitals and other care delivery settings that provide disease management and chronic care services. Benefits of Joint Commission accreditation and certification include: Strengthened community confidence in the quality and safety of care, treatment and services, Provides a competitive edge in the marketplace, improves risk management and risk reduction, Provides education on good practices to improve business operations, provides professional advice and counsel, enhancing staff education, enhances staff recruitment and development, it is recognized by select insurers and other third parties, and may fulfill regulatory requirements in select states.

The Joint Commission has accredited hospitals for more than 50 years. The Joint Commission currently accredits approximately 91 percent of the nation’s hospitals. This includes 4,250 general, children’s, long term acute, psychiatric, rehabilitation and surgical specialty hospitals.

Any health care organization may apply for Joint Commission accreditation under the Hospital Accreditation Standards if all the following requirements are met. These requirements include; 1) The organization is in the United States or its territories or, if outside the United States, is operated by the U.S. government, under a charter of the U.S. Congress, 2) The organization assesses and improves the quality of its services. This process includes a review of care by clinicians, when appropriate, 3) The organization identifies the services it provides, indicating which services it provides directly, under contract, or through some other arrangement, 4) The organization provides services addressed by the Joint Commission’s standards.

The Joint Commission also has standards that address the hospital’s performance in specific areas, and specify requirements to certify that patient care is being provided in a safe secure and safe environment. These standards are developed in consultation with health care experts, researchers and providers as well as consumers, measurement expert and purchasers. Standards in each of the performance areas are reviewed meticulously and updated every three years. These standards include; Ethics, Rights and Responsibilities, Management of the Environment of Care, Provision of Care, Treatment and Services, Management of Human Resources, Medication Management, Management of Information, Surveillance, Prevention, and Control of Infection, Medical Staff, Improving Organization Performance, Nursing, and Leadership.

To earn and maintain accreditation, a hospital must undergo an on-site survey by a Joint Commission survey team. Joint Commission surveys are unannounced and occur 18 to 39 months after the previous survey. The survey team can include one or more health care professionals, including a physician, nurse, life safety code specialist, or hospital administrator who has senior management level experience. The objective of this survey is to provide education and guidance that will help the staff to continue to improve the hospital’s performance. This processes evaluates actual care processes by following patients through the care, treatment and services they received. By doing so, key operational systems that directly affect the quality and safety patient care can be analyzed.

The accreditation process is continuous, data-driven and focuses on operational systems critical to the safety and quality of patient care. Key components of the process are:
• A Periodic Performance Review (PPR): This a required annual review that evaluates the health care organizations own compliance with applicable standards and develops a Plan of Action for identified areas of non-compliance.
• Tracer methodology: This is an on-site evaluation of standards compliance in relation to the care of the patients. This actively engages all direct caregivers in the accreditation process.
• Priority Focus Process (PFP): An on-site survey that focuses on patient safety and quality of care. Automation is used to gather pre-survey data from multiple sources and then applies the data.
• Unannounced Survey: These were implemented to enhance the credibility of the accreditation process and to ensure that surveyors observe organization performance under normal circumstances.

Information about the safety and quality of accredited hospitals is available to the public at Quality Check®, www.qualitycheck.org. This comprehensive listing includes each accredited hospital’s name, address, telephone number, accreditation decision, current accreditation status and effective date, and its Quality Report. Quality Reports include detailed information about a hospital’s performance and how it compares to similar hospitals.

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