The Joint Commission

The standards of the Joint Commission are a foundation for an objective evaluation process the may help healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key for providing safe high quality care services. The Joint Commission’s standards set goal expectations of reasonable, achievable and surveyable performance of an organization. Only new standards that are relative to patient safety or care quality, have positive impact on healthcare outcomes, and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develop these standards.

The survey process is designed to be unique to each organization, consistent, and supportive of the organizations attempts to improve healthcare performance. During the survey, the Joint Commission evaluates the performance of processes aimed to improve patient outcomes. The assessment is done by evaluating an organizations compliance with standards in the manual based on the following key functions:

Tracing care that is delivered to patients

Verbal and/or written information given to the Joint Commission

Visual observations and interviews performed by the Joint Commission surveyors

Documents provided by the organizations

“Joint Commission surveys are unannounced, with a few exceptions, such as with the Bureau of Prisons or Department of Defense facilities. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. For example, if an organization’s last survey was January 1, 2009, it could have its survey as early as July 1, 2010 or as late as April 1, 2012 (18 to 39 months).”

The decision proces...

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... internal regulatory accreditation survey which was coordinated and conducted by the Allina regulatory leads from across the system. The surveys are designed to replicate an actual Joint Commission survey by incorporating the same patient tracer methodology utilized by TJC. Non-compliant internal findings were evaluated by responsible individuals and corrective actions were put in place to bring the requirements into compliance. The internal survey findings were entered into the ARAS tool and became helpful adjuncts during the preparation of the 2010 PPR. A dedicated heart failure disease specific certification team worked diligently throughout the year to prepare the organization for a 2011 TJC certification survey. The application for heart failure program certification survey was submitted to the TJC in December 2010 with an anticipated site visit in early 2011.”