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How Doctors Can Help Prepare for The Joint Commission Accreditation

By October 9, 2023Providers

The Joint Commission is an independent, private, not-for-profit organization that accredits and certifies 20,000 healthcare organizations and programs across the United States. TJC operates in all but three states, helping to create a single general unifying criterion for medical provider accreditation and performance measurement. Around 80% of US hospitals are accredited by TJC.

The Joint Commission accredits healthcare organizations including hospitals, nursing homes, ambulatory care centers, behavioral health facilities, home care organizations, and others. Its primary goal is to ensure that these organizations provide safe, high-quality, and outcome-focused care to patients.

Achieving Joint Commission accreditation is seen as a mark of excellence in healthcare and demonstrates an organization’s commitment to promoting rigorous quality and safety standards. This is reflected in the Commission’s history. TJC was born from a need to bring more consistency to hospital operations and performance in the mid-20th century. However, accreditation began to have an “official” impact in 1965, when the federal government first acknowledged that a hospital meeting TJC standards was also eligible for Medicare funds.

Now, TJC works globally to further its mission of accreditation, publication, education, and consultation while continuously updating and improving its joint accreditation processes. Meeting accreditation and associated standards can boost public confidence in a healthcare organization. It may be a requirement for insurance provider or government agency reimbursement.

To achieve accreditation, healthcare organizations undergo a thorough evaluation process, which includes assessments of their compliance with a set of independent quality and safety standards established by The Joint Commission. The accreditation process involves on-site surveys, reviews of policies and procedures, interviews with staff, and assessments of the organization’s performance in various areas related to patient care and safety. TJC can also assist with helping healthcare teams improve their communication and reduce medical mistakes.

TJC’s Accreditation Review Objectives

TJC’s core offering is its on-site survey conducted triannually at healthcare organizations and programs that request it. The objective is to assess compliance with TJC standards which promote a range of healthcare missions with an emphasis on patient well-being, satisfaction, and health outcomes. These criteria or data points are collectively known as Performance Measures.

TJC divides its Performance Measures into two categories: accountability and non-accountability measures. Accountability measures are those most closely aligned with patient outcomes. Non-accountability measures are those that fall outside patient care but still have significant affect on the overall delivery of healthcare services. TJC process also aims to further systemic healthcare goals such as healthcare equity, sustainability, and adequate access to necessary services such as emergency care and workplace violence prevention.

Impact on Healthcare

TJC’s primary accreditation and improvement process uses what’s called tracer methodology. This approach examines a hospital or health organization’s care delivery through a narrowly focused lens, allowing its quality to be assessed at the patient level. Its application helps evaluate care coordination, communication, departmental procedures, infection control practices, and medication management across the entire organization through the whole care continuum.

Impact on Organizations

While tracer criteria are largely standardized, TJC works to expand the overall scope of accreditation to include multiple types of care including inpatient, outpatient, disease-specific, and population medicine. The feedback produced by TJC evaluation process is designed to help identify gaps and weaknesses early before they become a serious problem for patient care.

In response to criticism, its process of warning healthcare organizations too far in advance of its accreditation assessment has since been modified. Starting in 2017, TJC revised its announcement process to integrate a non-announcement (surprise visit) component.

Impact on Clinicians

TJC works to align its assessment and accreditation processes to the clinical delivery of care to ensure a focus on quality and patient outcomes. The tracer methodology uses a small-scope lens of following individual patients to examine larger systemic processes. This is useful for the clinician because it allows them to extrapolate from a single patient the impact of their healthcare services overall. The tracer starts with triage and proceeds through screening, radiology, admission, laboratory services, treatment, discharge or transfer, and follow-up infrastructure. It examines care delivered by a range of clinical personnel including physicians, physician assistants, nurse practitioners, and nurses.

For clinical programs either within healthcare systems or operating independently, the tracer methodology can be applied to services rendered to medically high-risk and demographically vulnerable patients to ensure they are treated objectively and with respect.

Prepare for Accreditation Evaluation

TJC accreditation criteria and the process of evaluation evolve frequently to become more objective, actionable, and thorough. However, there are TJC resources that can help doctors and administration prepare for accreditation. Additionally, your hospital or organization will select a single individual, usually a physician or high-level administrator, to carry out the performance review; well-prepared doctors make great candidates for this role.

TJC provides performance measurements across these healthcare domains and more:

  • Cardiac care (within all departments)
  • Emergency department care
  • Behavioral health and in-patient psychiatric services
  • Palliative care
  • Perinatal care
  • Outpatient services
  • Residential care and assisted living
  • Health care staffing
  • Substance use
  • Total knee and hip replacement

Physicians can familiarize themselves with the evaluation criteria of the areas relevant to their practice. In the case of administrators, they may want to examine the relationship between the delivery of care and the internal procedural mandates associated with each.

Additional Resources from The Joint Commission

TJC makes available a number of resources available to healthcare organizations including those intended to address specific deficiencies or areas of risk within the organization. For example, products like their Targeted Solutions Tools® work by focusing on one small but impactful aspect of healthcare delivery. For instance, their hand hygiene tool quantifies a single infection control throughout a health organization.

Additional TJC resources are intended to promote change by improving healthcare at the systemic level with evidence-based interventions that promote healthcare quality and equity.

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