Regulatory Agency Paper

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1 April 2016

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The Joint Commission (TJC) is the nation’s oldest and largest accrediting body in health care that sets the standards for quality care. It is a non-profit and independent organization that surveys and accredits more than 20,000 healthcare organizations in the United States. Joint Commission accreditation and certification is known to be the symbol of quality in an organization’s assurance in enduring certain performance standards. Organizations undergo an onsite survey by a survey team from The Joint Commission at least every three years to earn and maintain the gold seal of approval with the exception of laboratories. Laboratory accreditation by The Joint Commission is every two years. Structure

The Joint Commission was founded in 1951 whose primary purpose was to provide voluntary accreditation for meeting established minimum quality standards. According to The Joint Commission, the standards of quality were reformed in 1970 to represent the highest achievable levels, instead of minimum necessary levels. This movement spearheaded the current form of survey where in a continuous quality improvement is promoted. TJC was used to be called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) back in 1987 and was recently changed to The Joint Commission (TJC) after changing its trademark in 2007.

According to The Joint Commission, it 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 (The Joint Commission, 2014). Effects on Health Care

Numerous health care organizations are subjected to inspection and accreditation. Nursing homes, physician’s clinics, surgery centers, behavioral health facilities, hospitals, and home health care providers are subjected to surveys to earn an accredited status. Accreditation status is crucial in any health care organization as it is an integral part of its individual state licensure. Once accreditation status is achieved, the facility is recognized as an organization that meets quality and is committed to meeting performance standards set by The Joint Commission. Subsequently, state licensure of a health care organization is much more difficult and impossible to achieve if the organization fails its inspection from TJC. State licensure is a required necessity to open any health care facility, without it, it cannot legally open its doors for business.

It is important for health care organizations to educate and train its employees in promoting quality as it relates to customer satisfaction. Patient satisfaction is crucial in health care organization since Medicare reimbursement rate is dependent on its performance. Maintenance of a high score with Hospital Consumer Assessment of Healthcare Providers and Systems, also known as, HCAHPS should be considered a priority. It is crucial for the hospital leadership to recognize that poor-quality care can affect an organization’s outcome and failure to integrate risk management and quality efforts can lead to partial and ineffective results. Standards for leadership in TJC recognize three leadership groups: the governing body, the chief executive and other senior managers, and the leaders of the licensed independent practitioners. Code of Federal Register

The Code of Federal Regulations (CFR) is a centralized system for the federal government to communicate up-to-date legislation from the executive department or the agencies of the federal government to the public. The Federal Register System has two major publications. One is the Federal Register and the second is the Code of Federal Regulations (CFR). “The Federal Register is published and issued every federal working day. Legislation is published first as a proposed rule followed by a comment period. The comment period is a time the public can give their input on the proposed rule. Once the rule is finalized, it becomes a legal document a minimum of 30 days after publication in the Federal Register. These final rules are then codified and published annually in the CFR. The Federal Register and the CFR must be used together to determine an up-to-date stipulation of a ruling” (Understanding the Code of Federal Regulations, 2014). CFR is divided into 50 titles that represent a wide area of subjects relating to Federal regulations. Health care facilities belong to CFR 42 part 35. Duties

As a part of CFR 42, The Joint Commission requires health care facilities to report sentinel events. In 1998, TJC started to require the reporting of one specific type of medical error or serious adverse event called sentinel event. It is critical for organizations to perform a root cause analysis of the event to identify the true underlying cause. This process focuses on the fact that most events are the result of system problems and are not cause for individual blame. Centers for Medicare and Medicaid Services

The Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) are embedded within the TJC standards, along with additional standards covering patient safety and quality of care. The Joint Commission is an authorized accrediting organization by the CMS. A hospital accredited by TJC is deemed to meet all Medicare requirements for hospitals. However, there are special conditions for psychiatric hospitals that apply. Organizations involve in providing mental health care must have a separate TJC certification in addition to the main hospital accreditation. Successful accreditation is based on the facility’s ability to correct deficiencies so there is no downside to discovery of issues during the survey process. TJC Accreditation and Certification

A multi-disciplinary inspection team spends at four days in the hospital, depending on the size of the facility. Standards that measure plant safety, medical staff, quality assurance, department services and the current processes of the hospital to improve the quality of its services are surveyed. The Governing Board has an active role in in the accreditation process. According to The Joint Commission organization, it wants to see methods and systems in place to ensure that the governing board has a supervision role in the credentialing of the medical staff, quality assurance and continuous improvements of the care provided by the hospital (The Joint Commission, 2014). The Joint Commission awards a three-year accreditation to hospitals that meet its standards. In some cases, it makes receiving accreditation part of meeting certain standards between surveys.

If these standards are not met, it can result to a conditional accreditation or denial of accreditation. Hospitals that are accredited are automatically eligible to participate in the Medicare program. Accreditation or Medicare certification is required for participating in most managed care programs. The Joint Commission performs unannounced surveys, except for initial surveys. The hospital receives notification of inspection at 6 am on the day of survey. The purpose of every survey is to verify compliance with the defined standards. Health care organizations must abide by the standards defined according to the performance expectations and processes to deliver quality care. According to The Joint Commission, 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 (The Joint Commission, 2014). Surveyors will usually leave the premises of the facility after a survey if there are no immediate threats found to patient lives without taking any direct actions in the facility’s operations. The survey report with Requirements for Improvement or RFI will be published. The organization has forty five to sixty days to correct the RFI notations as Evidence of Standards Compliance. There has not been a case in health care accreditation survey wherein the organization received a perfect score. Most organizations receive at least three RFIs as The Joint Commission continues to promote the value of quality in their standards. Conclusion

It is necessary that health care entities such as hospitals, clinics, long term care facilities, and other health care organizations enhance their efforts in the quality of services they provide by participating in various performance improvements tools and activities. In doing so, the mandates of the Federal government are met and as well as the standards of The Joint Commission. The Joint Commission accredited organizations have been proven to achieve and provide the highest level of performance and service to their patients. Health care organizations must adhere to the provisions in the rules and regulations of the Condition of Participation (CoP) mandated by The Centers for Medicare and Medicaid Services (CMS). Preparation for a TJC survey is a challenging process as it requires an intensive assessment process of policies and procedures relative to the standards of care by The Joint Commission. To obtain accreditation, a healthcare organization must be proven in compliance with all the standards regulatory standards mandated by the State and Federal government.

Centers for Medicare & Medicaid Services. (2014). CMS. Retrieved from Federal Register. (2014). Code of Federal Regulations (CFR). Retrieved from Greenfield, D. (2008, January 18). Health Sector Accreditation Research: A Systematic Review. International Quality in Health Care, 20(3), 172-183. doi:10.1093/intqhc/mzn005 The Joint Commission. (2014). Facts abou The Joint Commission. Retrieved from Understanding The Code of Federal Regulations. (2014). Retrieved from

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"Regulatory Agency Paper" StudyScroll, 1 April 2016,

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"Regulatory Agency Paper" StudyScroll, Apr 1, 2016. Accessed Jan 31, 2023.

"Regulatory Agency Paper" StudyScroll, Apr 1, 2016.

"Regulatory Agency Paper" StudyScroll, 1-Apr-2016. [Online]. Available: [Accessed: 31-Jan-2023]

StudyScroll. (2016). Regulatory Agency Paper. [Online]. Available at: [Accessed: 31-Jan-2023]

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