The Joint Commission is an independent, not-for-profit organization that purportedly accredits and certifies more than 19,000 health care organizations in the United States. The Joint Commission, About The Joint Commission; available at http://jointcommission.org > About Us (last visited April 12, 2012). While accreditation is technically a voluntary process, through which accrediting bodies like The Joint Commission visit a facility to perform quality and process checks, it is also relied upon by state agencies in all fifty states in lieu of specific state licensure requirements. The Joint Commission, State Recognition; available at http://www.jointcommission.org > Topics > State Recognition (last visited April 12, 2012). Consequently, if an organization fails to achieve accreditation, through either The Joint Commission or another similarly recognized body, the state licensure is much more difficult, if not impossible to achieve. Without state licensure, a healthcare facility cannot legally open its doors.
Hospitals are not the only bodies subject to accreditation, as doctors’ offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home healthcare services can also earn accredited status, which may serve as an integral component to state licensure. Receipt of accreditation is recognized as a symbol of quality reflective of an organization’s commitment to meeting performance standards. The Mission of the Joint Commission is “To continuously improve health care for the public . . . by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” The Joint Commission, About The Joint Commission; available at http://jointcommission.org > About Us (last visited April 4, 2012).
The roots of The Joint Commission lay in the American College of Surgeons (ACS), founded in 1913, which eventually lead to voluntary onsite inspections of hospitals in 1918. In 1951, The American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association joined forces with the ACS to create the Joint Commission on Accreditation of Hospitals (JCAH). JCAH was formed as an independent, not-for-profit organization whose primary purpose was to provide voluntary accreditation for meeting established minimum quality standards. It was not until 1970 that the standards of quality were reformed to represent the highest achievable levels, instead of minimum necessary levels. Thus the current form of survey was enacted, whereby there is a movement for continuous improvement, rather than a seal of approval for reaching an acceptable quality level. In 1987, the company was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which was shortened to today’s The Joint Commission after rebranding in 2007. Id.
The founding organizations of The Joint Commission continue to be represented on the board of the organization, with the exception of the Canadian Medical Association. The Joint Commission, About The Joint Commission; available at http://jointcommission.org > About Us > Facts About The Joint Commission (last visited April 4, 2012). The Joint Commission has three additional affiliated bodies, each a separate corporate entity: 1.) The Joint Commission Resources, which publishes educational offerings and consultation materials, 2.) Joint Commission International, established to extend the offerings of The Joint Commission to foreign nations, and 3.) The Center for Transforming Healthcare, created for accredited organizations to provide continuous solutions and guidance. The Joint Commission’s Division of Accreditation and Certification Operations performs field operations, including surveyor Management & Development, and scheduling of site visits. Duco, S. Podgorny, K. An Introduction to the Joint Commission and Accreditation Process, Presented February 28, 2012; materials and recording available with author.
The general eligibility requirements for an organization to become accredited is for an online application to be completed, to be located within the United States territory, and to pay the accreditation fee. The accreditation annual fees for hospitals are based upon the size and the service complexity, ranging from $2,180 to $37,245. The Joint Commission, Facts About Hospital Accreditation; available at http://jointcommission.org > Accreditation > Hospital > Facts About Hospital Accreditation (last visited April 4, 2012). Accreditation fees include the application fee and access to educational materials, but not the complete survey costs. Travel expenses reimbursed for the surveyors, targeted survey preparation, also known as “consulting,” are each available for additional costs. Joint Commission Resources, Experts in Health Care Consulting, available at: http://www.jcrinc.com/> Consulting (last visited April 12, 2012).
The accreditation onsite survey is conducted once every three years using a specific agenda, formed using the Survey Activity Guide provided to the organization in preparation for the event. The Joint Commission, 2012 Survey Activity Guide; available at http://jointcommission.org > Accreditation > Hospital > Survey Activity Guide (last visited April 4, 2012). Each survey is unique based upon the class of organization and programs available for accreditation. The four most common survey types are: 1. Full Unannounced – the survey event that occurs once every three years in order to reestablish accreditation, 2. Initial Unannounced – the first survey event to establish accreditation, 3. Periodic Performance Review- option 2 - an optional, consultative survey in non-survey years, and 4. Office of Quality Monitoring (Unannounced) – in response to complaints lodged or media reports that an undesirable event or conditions are occurring, done to determine if a special full survey is needed. Duco, S. Podgorny, K. An Introduction.
Each survey is performed to verify compliance with delineated standards. The standards define the performance expectations, structures, and processes that must be in place for an organization to deliver quality care. Standards are not scored; rather, each standard contains subpart Elements of Performance (EP), which are scored on “satisfactory compliance” or “insufficient compliance” levels. EPs amount to specific actions, processes, or structures that must be fulfilled to achieve the goal of a standard. It is the EP compliance score that forms the basis for an organization’s overall compliance with a specific standard. Id.
If no immediate threats to patient lives are found, the surveyors will leave without taking any direct action in the organization’s operations. The results of a survey event are published in a Survey Report, with Requirements For Improvement (RFI) included. Because the standards are written with Joint Commission values with maximum-possible quality, an organization is likely to receive at least three RFIs, to promote the continuous strive for quality improvement. Id. After the Survey Report has been submitted, organizations have 45 – 60 days to achieve Evidence of Standards Compliance to rectify RFI notations. The Joint Commission, From Survey Report to Accreditation Decision; available at http://jointcommission.org > Accreditation > Hospital > How to Become Accredited (last visited April 4, 2012).
Duco, S. & Podgorny, K. An Introduction. The accreditation decision is rendered thereafter.
Although the onsite survey events are said to be unscheduled, the site visits occur once every three years. Based upon the triennial cycle and placement of the ten black out dates in the application, a provider can have a reliable expectation of when to expect surveyors. This practice provides facilities with the opportunity to alter their ordinary behaviors in order to be “survey ready.” It is akin to being on their best behavior, rather than allowing a true evaluation of day-to-day operations. Admittedly, The Joint Commission is combatting this criticism with intracycle monitoring; composed of two touch points in the three year accreditation cycle, one 10-12 months after the triennial survey, and the second 18-24 months after. Duco, S. & Podgorny, K. An Introduction. Consequently, healthcare organizations are held accountable to the performance standards once a year, with resources for addressing patient safety and quality concerns. Additionally, although the standards put forth by The Joint Commission are purportedly in excess of federal safety and quality of care requirements, they are often used by plaintiffs’ attorneys as minimum standards of care in malpractice suits. Therefore, as The Joint Commission raises the hypothetical quality bar beyond the reach of practicing physicians, liability attorneys have a veritable treasure trove for negligence litigation.
The benefits of Accreditation are based upon the reputation of The Joint Commission, as is evident in all 50 states in adopting some form of deference to The Joint Commission’s accreditation standard. As a historical promoter of high quality care, the Joint Commission enjoys a respected status in the medical community, which is often used to give accredited organizations a competitive edge in the healthcare market. The Joint Commission, The Value of Joint Commission Accreditation; available at http://jointcommission.org > Accreditation > Hospital (last visited April 4, 2012). In order for a healthcare organization to receive payment from the Medicare or Medicaid programs, it must meet the eligibility requirements including compliance with mandated Conditions of Participation (CoPs) and Conditions for Coverage. Centers for Medicare & Medicaid Services, Overview; available at: http://www.cms.gov > Regulations and Guidance> Conditions for Coverage (CfCs & Conditions of Participations (CoPs)> Overview (last visited April 12, 2012). The Centers for Medicare & Medicaid services (CMS) has granted “deeming” authority to accreditation organizations, like The Joint Commission, that enforce standards that meet or exceed Medicare’s CoPs. Id. Thereby creating another benefit of accreditation: typically CMS will delegate quality checks to state agencies, who in turn sometimes delegate the site visit task to The Joint Commission, which would mean a hospital need only pass the triennial Joint Commission site visit in order to achieve Medicare’s CoPs compliance. Criticism of this practice includes the fact that The Joint Commission does not release how many organizations have failed to achieve accreditation, thus creating the perception that with the proper forms and the ability to pay, Joint Commission accreditation, and consequently state licensure and Medicare CoPs compliance can always be achieved.
The Joint Commission cites their office in Washington D.C. as a point of contact with CMS, which allows the organization to efficiently move standards forward in accordance with quality and safety standards discovered through Joint Commission , often before new CMS requirements are issued. Duco, S. & Podgorny, K. An Introduction. Additionally, accredited bodies may receive a decrease in liability insurance costs. Id.
The Joint Commission has goals to transition from solely periodic reviews to those reviews in addition to intracycle monitoring. The goal to help accredited entities become highly reliable organizations is evident in the newly planned requirements for accreditation that would require organizations to submit self-evaluations, with the option of involving the Joint Commission in improvement plans during non-survey event years. The future movement of the organization is to identify risk points specific to each organization, and to provide accredited entities with resources and solutions for addressing quality issues.
Although the Joint Commission has built a reputable image in the health care market based upon the 19,000 organizations they do accredit, the organization may be losing ground in the accreditation market due to increased competition. Accreditation Commission for Health Care, Accreditation Association for Ambulatory Health Care, and URAC are just a few of the many accreditation bodies that have begun to gain ground in the health care market.
Health Lawyers thanks Allison Hay for authoring the original version of this article.