April 5th, 2010 in Resources


The Mission of the Joint Commission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.


The Joint Commission evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An independent, not-for-profit organization, JCAHO is the nation’s predominant standards-setting and accrediting body in health care. Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations. The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements. JCAHO accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain The Joint Commission’s Gold Seal of Approval, an organization must undergo an on-site survey by a JCAHO survey team at least every three years. (Laboratories must be surveyed every two years.)

Who is Eligible?

The Joint Commission provides evaluation and accreditation services for the following types of organizations:

  • General, psychiatric, children’s and rehabilitation hospitals
  • Critical access hospitals
  • Medical equipment services, hospice services and other home care organizations
  • Nursing homes and other long term care facilities
  • Behavioral health care organizations, addiction services
  • Rehabilitation centers, group practices, office-based surgeries and other ambulatory care providers
  • Independent or freestanding laboratories

JCAHO 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. The Joint Commission has a Health Care Staffing Services Certification Program and is developing a certification program for transplant centers and health care services.

Available Accreditation Programs

  • Ambulatory Care
  • Assisted Living
  • Behavioral Health Care
  • Critical Access Hospitals
  • Home Care
  • Hospitals
  • Laboratory Services
  • Long Term Care
  • Networks
  • Office-Based Surgery

Benefits of JCAHO Accreditation

  • Strengthens 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
  • Recognized by select insurers and other third parties
  • May fulfill regulatory requirements in select states

Standards and Performance Measures

JCAHO standards address the organization’s level of performance in key functional areas, such as patient rights, patient treatment, and infection control. The standards focus not simply on an organization’s ability to provide safe, high quality care, but on its actual performance as well. Standards set forth performance expectations for activities that affect the safety and quality of patient care. If an organization does the right things and does them well, there is a strong likelihood that its patients will experience good outcomes. The Joint Commission develops its standards in consultation with health care experts, providers, measurement experts, purchasers, and consumers.

The Accreditation Process

The on-site survey consists of staff, resident and family interviews, tours, observations, and review of selected documentation in an effort to understand how the systems are compliant with JCAHO standards.

JCAHO standards address a healthcare organization’s level of performance in specific areas – not simply what the organization is capable of performing, but what it actually does. Standards are based on maximum achievable expectations, and set forth performance expectations for activities that affect the quality of resident care.  The method of how to meet the performance objectives articulated in the standards is up to the organization.

Surveys are conducted by one Joint Commission long term care surveyor, who has long term care experience, including management experience. If other accreditation services are included in the scope of the survey, the survey is conducted by a team of Joint Commission surveyors. The composition of the team is based on programs surveyed, as determined from the information provided in its Request for Accreditation. All surveyors assess and provide consultation regarding all functions addressed by the standards.

Recent Changes in the Accreditation Process

In 2004, the Joint Commission introduced significant changes into the accreditation process. The new accreditation process shifts accreditation away from survey preparation to continuous standards compliance. To understand the changes in the process, there are several new terms to learn which explain the changes: Periodic Performance Review, Plan of Action, Measure of Success Priority Focus Process, Tracer Methodology, and Evidence of Standards Compliance.

Periodic Performance Review (PPR)

Organizations are required to participate in a mid-cycle evaluation of standards compliance called the Periodic Performance Review (PPR). Fifteen months after the completion of its last on-site survey an organization receives an electronic tool to assist in the Periodic Performance Review. The organization has three months in which to complete the assessment.

Completion of the assessment portion of the PPR will allow an organization to identify areas where it may not be in compliance with standards.  The goal of a Periodic Performance Review is to help organizations identify performance areas out of compliance, and to guide them along the road to correcting these non-compliant areas before the next on-site survey.

For those areas self-identified as out of compliance with Joint Commission standards, the organization will submit a Plan of Action to the Joint Commission along with Measures of Success that will substantiate that the standard has been brought into compliance.  Within the Joint Commission, there is a Standards Interpretation Group (SIG) whose responsibilities include answering organizations’ questions about interpreting and applying the standards. The SIG will review each organization’s Plan of Action and Measure of Success in a telephone interview and indicate whether the action plans, Measures of Success and timetables are acceptable to bring the standard into compliance.

During the next on-site visit following submission of a PPR, the surveyor will look for the measures of success that the organization provided as part of the Plan of Action. If at the time of on-site survey the surveyor finds less than 12 months of standards compliance, a requirement could result that would require resolution within 90 days after completion of the on-site review.

In response to concerns about legal disclosure of PPR information shared with the Joint Commission, two options to the full PPR are available to organizations. The first option allows the organization to perform the mid-cycle self-assessment, develop the plan of action and Measure of Success and discuss standards-related issues with Joint Commission staff without submitting the PPR or plan of action. The second option provides for the organization to undergo a mid-cycle survey (a fee will be charged to cover costs) and to submit a plan of action with Measures of Success for areas of non-compliance.

Priority Focus Process

Priority Focus is a new process that takes organization-specific pre-survey information and converts it into useful information that includes priority focus areas and clinical service groups to help the surveyor focus the on-site activity.  This will allow surveys to be more customized to each organization.  The on-site survey agendas will be developed based on information gathered about the organization from several sources, and will be structured to spend more time on areas that have been challenges for the organization in the past. Organizations should find the Priority Focus Process information driven and focused on their specific performance.

Data sources that will contribute to the Priority Focus Process will include:

  • Previous requirements for improvement from past surveys
  • Data from the completed Application for Accreditation
  • Performance Measurement data such as ORYX measures or MDS
  • Quality Indicator profiles or Quality Measures
  • Complaints about the organization (if any) received by the Joint Commission’s Office of Quality Monitoring

(Priority focus process for initial organizations will be done, although the data set from which to pull information will be limited.)

For example, let’s say that the PFP data for a long term care organization identifies residents in need of pain control as a clinical service group and assessment and care as a top priority focus area.  The surveyor will use these two pieces of information to focus the on-site review.  By reviewing a list of current residents, the surveyor will select a resident needing pain control and follow the care provided to that resident through the tracer methodology described below.  The surveyor will focus attention on the assessment of that resident’s pain, and steps taken as a result of that assessment.

Tracer Methodology

Tracer Methodology is a revision to the on-site survey that makes the resident care experience the ‘table of contents’ to assess standards compliance.  Using the information from the Priority Focus Process, the surveyor(s) will select residents from an active resident list to ‘trace’ their experience throughout the organization. Residents typically selected are those who have received multiple or complex services or have been triggered by the MDS quality indicators or quality measures.

The surveyor(s) will follow the resident’s experience, looking at services provided by various individuals and departments within the organization, as well as ‘hand-offs’ between them.  This type of review is designed to uncover systems issues, looking at both the individual components of an organization, and how the components interact to provide safe and quality resident care.

The number of residents followed under the Tracer Methodology will depend on the size and complexity of the organization, and the length of the on-site survey.

Evidence of Standards Compliance

The report left with the organization at the end of the on-site survey will be the final report, and will identify any standards that were scored as partial or non-compliant.  For those standards scored as non-compliant, the organization will have to submit Evidence of Standards Compliance (ESC) to the Joint Commission within ninety days of the completion of the survey (45 days after January 1, k 2006).  ESC includes evidence that the organization is now in full compliance with the standard and quantifiable Measures of Success (MOS) for all partial or non-compliant Elements of Performance.  These Measures of Success will show that compliance has been sustained over time.  Once the ESC and MOS are approved by the Joint Commission, the organization moves into the accredited decision status.  The organization submits MOS data at the end of four months to show that it has maintained compliance over time with the standards.

Accreditation Outcomes

After the on-site survey, organizations do not receive an overall score or grid element score, and no scores are shared with the health care organization. The final accreditation decision will be made after The Joint Commission receives and approves an organization’s Evidence of Standards Compliance submission and its Measures of Success (when required). The accreditation decision categories are:

  • Accredited ― The organization demonstrates compliance with all of the standards at the time of the on-site survey, or it resolves Requirements for Improvement via an acceptable ESC submission.
  • Provisional Accreditation ― All Requirements for Improvement have not been addressed in the ESC submission, or the organization has failed to achieve an appropriate level of sustained compliance as determined by a Measure of Success result (when required).
  • Conditional Accreditation ― Number of standards scored not compliant is between two and three standard deviations above the mean number of not compliant standards for organizations in that accreditation program. The organization must undergo an on-site follow-up survey.
  • Preliminary Denial of Accreditation ― Number of standards scored not compliant is three or more standard deviations above the mean number of not compliant standards for organizations in that accreditation program. There is justification to deny accreditation, but the decision is subject to appeal.
  • Denial of Accreditation ― The organization has been denied accreditation, and all review and appeal opportunities have been exhausted.
  • Preliminary Accreditation ― The organization demonstrates compliance with selected standards in the first of two surveys conducted under the Early Survey Policy Option 1. This decision remains in effect until one of the other official accreditation decision categories is assigned, based on a complete survey against all applicable standards approximately six months later.