Ethan Rhodes
The Joint Commission (TJC) is an independent, not-for-profit organisation that accredits and certifies more than 20,000 healthcare programs and organisations in the United States. The TJC conducts on-site surveys of hospitals and healthcare organisations every two to three years to assess their performance and compliance with safety standards. These surveys are designed to be organisation-specific, consistent, and supportive of the organisation's efforts to improve quality. During the survey, TJC surveyors select patients randomly and use their medical records to evaluate standards compliance, talking to doctors, nurses, and other staff who interacted with the patient. The TJC aims to avoid medical errors and non-compliance in healthcare organisations by evaluating factors affecting patient safety and care, such as multitasking, interruptions, worker fatigue, and communication issues.
| Characteristics | Values |
|---|---|
| Number of healthcare organizations accredited by The Joint Commission | 20,000-22,000 |
| Type of organization | Independent, not-for-profit |
| Frequency of surveys | Every 2-3 years |
| Accreditation validity | 2-3 years |
| Accreditation decision time | 2 weeks to 2 months |
| Survey preparation time | None, may be announced at the start of the week |
| Survey length | Determined by information supplied by the organization |
| Survey focus | Patient safety and quality, care processes, technology |
| Survey objectives | Evaluate the organization, provide education and guidance |
| Accreditation fee | $46,000 annually |
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What You'll Learn
The Joint Commission's survey process
The Joint Commission (TJC) is an independent, not-for-profit organisation that accredits and certifies over 20,000 healthcare organisations and programs in the United States. It is the oldest and largest standards-setting and accrediting body in US healthcare. The Joint Commission employs around 1,000 surveyors, including doctors, nurses, hospital administrators, and other healthcare professionals.
The Joint Commission typically conducts its accreditation surveys every three years. Accredited healthcare organisations are reviewed every two to three years. Hospitals and healthcare facilities that wish to be accredited by the TJC pay an annual fee of around $46,000. Accreditation is awarded for three years, except for laboratories, which are awarded for two years.
The on-site survey process is data-driven and focused on patient safety and quality. It evaluates actual care processes and technology, and survey length is determined by the information supplied by the organisation in its application. The objectives of the survey are to evaluate the organisation using standards and elements of performance, and to provide education and "good practice" guidance to inspire continuous improvement. The survey process is designed to be organisation-specific and consistent, and to support the organisation's efforts to improve quality.
The TJC visits hospitals between 18 and 36 months after their last survey, and they select patients to complete a survey about their hospital stay. The TJC usually announces its visit at the start of the week and appears on the day of the announcement, so the visits are considered unannounced as healthcare organisations must continuously prepare. Shortly after the survey, an organisation's report of survey findings is posted on its secure Joint Commission Connect extranet. If an organisation does not receive any requirements for improvement, the accreditation decision becomes official at the same time as the organisation's summary report.
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Accreditation and its benefits
Accreditation in healthcare is a voluntary program in which trained external peer reviewers evaluate a healthcare organisation's compliance and compare it with pre-established performance standards. The Joint Commission, for example, accredits and certifies over 22,000 healthcare organisations and programs in the United States, including hospitals and healthcare organisations that provide services like ambulatory and office-based surgery, behavioural health, home healthcare, and laboratory and nursing care services.
The Joint Commission surveyors are highly trained experts in various healthcare fields, including doctors, nurses, hospital administrators, and laboratory medical technologists. They conduct on-site surveys, selecting patients randomly and using their medical records to evaluate standards compliance. They talk to the doctors, nurses, and other staff who interacted with the patient, and they observe the care provided, often speaking to the patients themselves.
Accreditation is a continuous process that has multiple benefits for healthcare organisations. It helps to evaluate and enhance the quality of healthcare, complementing other performance improvement strategies. It supports operational efficiency by identifying gaps, improving cross-departmental collaboration, and refining processes. Accreditation also lowers the length of patient stays, reduces readmissions, and protects against Recovery Audit Contractor (RAC) issues through better documentation and care practices. It ensures a commitment to higher standards, giving accredited facilities a competitive edge and streamlining diagnosis and treatment processes.
There is evidence to suggest that accreditation programs improve clinical outcomes for a wide range of clinical conditions, including the management of AMI, trauma, ambulatory surgical care, infection control, and pain management. However, one of the barriers to the implementation of accreditation programs is the skepticism of healthcare professionals regarding the positive impact of such programs on healthcare quality. Furthermore, studies have shown that accreditation can negatively impact professionals' job stress, with some studies indicating higher anxiety and depression among nurses during the accreditation preparation phase.
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Survey frequency
The Joint Commission (TJC) is an independent, not-for-profit organisation that accredits and certifies more than 20,000 health care organisations and programs in the United States. The TJC aims to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. The TJC conducts its accreditation surveys every three years, although this can vary between 2 and 3 years. The survey process is critical for ensuring that healthcare organisations, such as hospitals and clinics, meet specific standards of care and operational procedures designed to promote patient safety and quality of healthcare services.
During these surveys, the TJC assesses various aspects of healthcare organisations, including management practices, patient care, and adherence to safety protocols. Healthcare facilities must comply with the Commission's standards not only to achieve accreditation but also to maintain it over time. These regular evaluations help ensure that the organisations uphold high-quality healthcare practices that benefit patients.
The on-site survey process is data-driven, focused on patient safety and quality, and evaluates actual care processes and technology. Survey length is determined by the information supplied by the organisations on their application. The objectives of the survey are to evaluate the organisation using standards and elements of performance and provide education and "good practice" guidance to inspire staff to continually improve the organisation's performance.
The TJC visits hospitals between 18 and 36 months after their last hospital survey, and they select patients to complete the survey about their hospital stay. TJC surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other healthcare professionals. During the survey, surveyors select patients randomly and use their medical records to evaluate standards compliance. As surveyors trace a patient's experience in a healthcare organisation, they talk to the doctors, nurses, and other staff who interacted with the patient. They also observe doctors and nurses providing care and often speak to the patients themselves.
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Surveyors and their methodology
The Joint Commission (TJC) is an independent, not-for-profit organisation that accredits and certifies more than 20,000 healthcare organisations and programs in the United States. It is the oldest and largest standards-setting and accrediting body in US healthcare. The Joint Commission employs approximately 1,000 people in its surveyor force, including doctors, nurses, hospital administrators, laboratory medical technologists, and other healthcare professionals.
The TJC aims to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. About 70 to 80% of its functions directly address patient safety. The TJC has specific quality measures to hold healthcare organisations accountable for health-related outcomes. It offers an unbiased assessment of organisations' quality achievements in patient care and safety.
The TJC's on-site survey process is data-driven, focused on patient safety and quality, and evaluates actual care processes and technology. The survey length is determined by the information supplied by the organisation in its application. The survey objectives are to evaluate the organisation using standards and elements of performance, and to provide education and "good practice" guidance to inspire staff to continually improve the organisation's performance. The TJC adopts a tracer methodology to survey hospitals on compliance with safety standards. The on-site survey identifies hospital performance issues through individual tracer activity, system tracer activity, and accreditation program-specific tracers. During the survey, Joint Commission surveyors select patients randomly and use their medical records to evaluate standards compliance. They trace a patient's experience in a healthcare organisation, talking to doctors, nurses, and other staff who interacted with the patient. They also observe doctors and nurses providing care and often speak to patients themselves.
The Joint Commission typically renders accreditation decisions two weeks to two months after the survey. Accreditation is awarded for three years, except for laboratory accreditation, which is awarded for two years. Healthcare organisations undergo these triennial surveys to maintain their accredited status, which signifies compliance with established quality and safety standards.
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Patient safety and quality
The Joint Commission (TJC) is an independent, not-for-profit organization that accredits and certifies over 20,000 healthcare organizations and programs in the United States, including hospitals. The TJC's primary goal is to ensure quality healthcare and patient safety, and it offers an unbiased assessment of healthcare organizations' quality and safety achievements.
The TJC conducts on-site surveys of healthcare organizations to evaluate their performance and patient safety standards. These surveys are typically conducted every two to three years, and organizations can receive an unannounced survey between 18 to 36 months after their previous full survey. The survey length is determined by the information supplied by the organizations in their applications. The TJC surveyors are highly trained experts in various healthcare fields, including doctors, nurses, and hospital administrators.
During the on-site surveys, surveyors randomly select patients and use their medical records to evaluate standards compliance and patient safety. They trace the patient's experience by talking to the healthcare staff involved in their care and often speaking to the patients themselves. The surveys focus on evaluating actual care processes, technology, and performance standards, including medication management, infection control, and preventing medical errors.
After the survey, the TJC provides a report of its findings, which includes any requirements for improvement (RFIs). If an organization meets all the standards, it receives accreditation. If not, the organization must develop plans of action to enhance safety and quality to satisfy the TJC's standards. The TJC's surveys are crucial for healthcare organizations to maintain their accredited status and continuously improve their practices to benefit patients.
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Frequently asked questions
The Joint Commission accredits and certifies more than 20,000 health care organizations and programs in the United States. It surveys hospitals every three years.
The Joint Commission's surveys are designed to ensure that hospitals meet specific standards of care and operational procedures to promote patient safety and quality of healthcare services.
Hospitals prepare for these surveys by actively engaging in continuous quality improvement initiatives. This includes staff training, policy development, and performance monitoring.
During the survey, Joint Commission surveyors randomly select patients and use their medical records to evaluate standards compliance. They talk to the doctors, nurses, and other staff who interacted with the patient and observe patient care.
Shortly after the survey, an organization’s report of survey findings is posted on its secure Joint Commission Connect® extranet. If an organization does not receive any requirements for improvement (RFIs), the accreditation decision becomes official.
