JCAHO Policies & Procedures

The Joint Commission on Accreditation of Healthcare Organizations, founded in 1951, officially changed its name in 2007 to The Joint Commission, but its mission is unchanged. The JC accredits and certifies health care organizations including hospitals, long term care facilities, laboratories, and small ambulatory practices with the goal of ensuring patient safety and outcomes. The thorough accreditation process is voluntary, but confers a standard of consumer confidence. The JC visits organizations every three years, assessing performance ranging from patient care to record keeping and from infection control to leadership.

Background

• By 2008, the JC was accrediting more than 17,000 U.S. health care organizations, including on its Board of Commissioners members from the American Colleges of Physicians and Surgeons, the American Hospital Association and the American Medical Association. Its services include education, advice and practice recommendations for psychiatric, children's and rehabilitation hospitals, home care and hospice organizations, acute care facilities and laboratories. The JC also certifies programs focused on areas such as kidney and heart disease, diabetes and stroke. In 2007, the JC expanded its role to 70 countries internationally.

Accreditation

• JC accreditation standards and policies are rigorous and demanding, requiring thorough preparation throughout an organization and much written information. An on-site team meets first with staff to plan the process and confers with organization leadership. The survey uses established statistical methods to interview patients, staff, or clients when examining processes of care and areas such as performance improvement and system-wide communications. In 2009, the JC added a Life Safety Code specialist to all site visits to evaluate the care environment.

Medical Standards

• The JC issues guidelines and policies, updated yearly, for each type of organization it examines. For hospitals, 2009 information is published in "The Joint Commission Revised 2009 Accreditation Requirements ... Hospital Accreditation Program." The 27-page manual details procedures to be followed hospital-wide, types of information to be presented and scoring criteria. Categories include management, staff guidelines, performance, licensure, nursing, and patient treatment.

Administrative Requirements

• JC categories for quality in hospital administration include human resources, leadership, safety and records. Many other policies are covered in JC documents, depending on the size and type of institution applying for accreditation.

Findings

• At the end of a site visit, the evaluation team meets with staff and leadership to discuss findings and make recommendations. A final decision is not announced at once, particularly if the organization receives notice of requirement(s) for improvement. In such cases, the organization must file evidence of compliance. It is possible for a health care entity to lose JC accreditation.