The Joint Commission About The Joint Commission

QUESTIONS – Joint Commission

What is the Joint Commission?

List the 5 benefits of Accreditation by the Joint Commission.

List the 4 patient-focused functions of the Comprehensive Accreditation Manual for Hospitals (CAMH)?

Can you explain what an accreditation survey is and what happens during the survey?

How long is an accreditation and certification award?

List the 7 Hospital National Patient Safety Goals for 2019.Include an example for each section how you as a respiratory therapist contribute to ensuring patient safety.

*** Use the information belowand the 2 attached PDF Files to answer the following questions:

About The Joint Commission

Q: What is The Joint Commission?

A:

Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, 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 accredits and certifies more than 21,000 health care organizations and programs in the United States, including hospitals and health care organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory and nursing care center services. An independent, not-for-profit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. The Joint Commission has two nonprofit affiliate organizations:

The Joint Commission Center for Transforming Healthcare

aims to solve health care’s most critical safety and quality problems and

Joint Commission Resources (JCR)

provides consulting services, educational services and publications.

Joint Commission International,

a division of JCR, accredits and certifies international health care organizations. Learn more about The Joint Commission at www.jointcommission.org. 

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Q: Is accreditation or certification mandatory?

A:

No. Health care organizations, programs, and services voluntarily pursue accreditation and certification.

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Q: What is an accreditation survey? What happens during an accreditation survey?

A:

Joint Commission surveyors visit accredited health care organizations a minimum of once every 39 months (two years for laboratories) to evaluate standards compliance. This visit is called a survey.  All regular Joint Commission accreditation surveys are unannounced.

Joint Commission surveyors are highly trained experts who are doctors, nurses, hospital administrators, laboratory medical technologists, and other health care professionals. The Joint Commission is the only health care accrediting body that requires its surveyors be certified.

During the survey, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care, and often speak to the patients themselves.

Joint Commission accreditation does not begin and end with the on-site survey. It is a continuous process. Every time a nurse double-checks a patient’s identification before administering a medication, every time a surgical team calls a” time out” to verify they agree they’re about to perform the correct procedure, at the correct site, on the correct patient, they live and breathe the accreditation process. Every three months, hospitals submit data to the Joint Commission on how they treat conditions such as heart attack care and pneumonia – data that is available to the public and updated quarterly on qualitycheck.org. Throughout the accreditation cycle, organizations are provided with a self-assessment scoring tool to help monitor their ongoing standards compliance. Joint Commission accreditation is woven into the fabric of a health care organization’s operations.

back to top Q: What do standards focus on?

A:

The Joint Commission’s state-of-the-art standards focus on patient safety and quality of care. The Joint Commission standards are updated regularly to reflect the rapid advances in health care and medicine. The hospital accreditation standards number more than 250, and address everything from patient rights and education, infection control, medication management, and preventing medical errors, to how the hospital verifies that its doctors, nurses, and other staff are qualified and competent, how it prepares for emergencies, and how it collects data on its performance and uses that data to improve itself.

back to top Q: How long does it take The Joint Commission to render an accreditation decision?

A:

The Joint Commission renders accreditation decisions two weeks to two months after the survey.

back to top Q: How long is an accreditation and certification award?

A:

Accreditation is awarded for three years, except for laboratory accreditation, which is awarded for two years. Joint Commission Disease-Specific Care Certification, Primary Stroke Center Certification, and Health Care Staffing Services Certification are awarded for two years.

back to top Q: Where can I find information about an accredited Health Care Organization?

A:

Joint Commission Quality Reports give the public information on the safety and quality of care for all Joint Commission accredited/certified health care organizations. Quality Reports are available online through Quality Check® at qualitycheck.org.  Quality Reports include:

Accreditation decision and date

Programs and services accredited by The Joint Commission and other bodies

National Patient Safety Goal performance

Hospital National Quality Improvement Goal performance

Special quality awards