FERRIS STATE UNIVERSITY
NURS 320
 Joint Commission on the Accreditation of Healthcare Organizations is a
private, nonprofit organization whose mission is to continuously improve
the safety and quality of care provided to the public; it does this through
the provision of health accreditation and related services that support
performance improvement in health care organizations.
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.
All people always experience the safest, highest quality, bestvalue health care across all settings.
(SAUNDERS, 2003) (TJI,2012)
(JCI, n.d.)
 1910 Ernest Codman, M.D., developed the “end result system of hospital
standardization.” This system allowed hospitals to track patient outcomes and
allowed hospitals to correct ineffective outcomes to allow similar cases to be
treated successfully in the future.
 1951 The Joint Commission on Accreditation of Hospitals (JCAH), a not-
for-profit organization is formed in Chicago, Illinois.
 1987 JCAH changes its name to the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO).
 1998 The Sentinel Event Policy is revised, effective April 1, to promote self-
reporting of medical errors and encourage health care providers to more
closely examine the root causes of these events.
(TJC , 2012)
 “The Joint Commission evaluates and
accredits more than 19,000 health
care organizations and programs in
the United States”.
 “The Joint Commission is the nation's
oldest and largest standards-setting
and accrediting body in health care”.
(TJC , 2012)
 Many medical facilities rely on JCAHO accreditation procedures
to indicate to the public that their particular institution meets
quality standards.
 JCAHO standards are not mandated, however it is recommended
that these guidelines should be considered when designing or
improving processes.
 Practitioners are expected to consider the recommendations
found in knowledge-based sources, such as professional medical
societies and physician organizations, nursing and allied
healthcare associations.
(SPATH, 2002)
 Implement evidence-based practices to prevent indwelling catheter-
associated urinary tract infections (CAUTI).
 Insert indwelling urinary catheters according to established evidence-based guidelines that
address the following:
 Manage indwelling urinary catheters according to established evidence-based
guidelines that address the following:
 Securing catheters for unobstructed urine flow and drainage
 Maintaining the sterility of the urine collection system
 Replacing the urine collection system when required
 Collecting urine samples
TJC , 2012)
 Measure and monitor catheter-associated urinary tract infection
prevention processes and outcomes in high-volume areas by
doing the following:
 Selecting measures using evidence-based guidelines or best practices
 Monitoring compliance with evidence-based guidelines or best practices
 Evaluating the effectiveness of prevention efforts
TJC , 2012)
 What Is Accreditation?
 “a process in which an entity,
separate and distinct from the
health care organization, usually
nongovernmental, assesses the
health care organization (in this
instance, the laboratory) to
determine if it meets a set of
requirements designed to improve
quality of care.”
 Who Can Gain Accreditation?
 Hospitals
 Doctor’s Offices
 Nursing Homes
 Office-based Surgery Centers
 Health Treatment Facilities
 Providers of Home Care Services
 Aids in improving patient safety
 Strengthens the communities confidence in the services and treatments
they are receiving
 Provides a competitive edge in the marketplace
 Improves risk management and risk reduction
 Attempts to decrease liability insurances
 Educates businesses to improve operations
 Provides professional advice and education to staff
 Enhances staff recruitment and development
 Gives authority for Medicare certification.
 Generally recognized by insurers and other third parties
 Helps develop a framework for organizational structure and management
 Helps fulfill regulatory requirements in select states
 Gives tools to accredited organizations
 Depends on the facility seeking accreditation.
 Depends on eligibility requirements
 Accreditation is voluntary.
 JCAHO surveyors come to the facilities where accreditation is sought for an
intense on-site review.
 Then facilities receives a report identifying its strengths and outlining what it
could improve.
 “At the conclusion of a survey, the Joint Commission issues a report listing
Requirements for Improvement (RFIs), areas where an organization must
respond with corrective action plans. There are two different kinds of RFIs”.
 “Direct impact RFIs: Direct RFIs are areas of sufficient concern that the Joint
Commission believes noncompliance could pose an immediate risk to patient
safety or quality of care. To avoid review of accreditation status by the Joint
Commission’s central office, a hospital of our type must receive fewer than
13 RFIs on the hospital survey and fewer than 5 RFIs on the laboratory
survey. Additionally, a hospital must submit a corrective action plan addressing
each direct impact RFI within 45 days”.
 “Indirect impact RFIs: Indirect impact RFIs are considered to pose a less
immediate risk to patient safety and quality of care. These RFIs do not have a
bearing on an accreditation decision, but are still relevant and important to
providing high-quality, safe patient care. A hospital must respond to these
findings with a corrective action plan within 60 days”.
(MGH, 2012)
 “The definition of “corrective action” is a structured effort to improve
suboptimal performance identified through the performance improvement
monitoring process. Corrective actions are not the end of the problem or
loop closure. Actions are to create a forward momentum for an outcome
change. Actions should be viewed as positive and multifaceted within a
variety of categories. Action plans can generally be categorized into three
areas: patient-specific, provider-specific or system-specific”.
 “Action plans should be dynamic, flexible and meaningful. Action plans
should emphasize positive change; include components of issue identification,
data analysis, model for implementation and evaluation and re-evaluation for
loop closure. This would be defined in a performance improvement plan”.
( SOCIALTEXT, 2012)
 Certain deficiencies found during a survey require audits to be completed
over a four month period of time. When these audits are started a goal of
90-100% should be set. These audits should show proof that the
deficiencies were fixed. If the facility’s goal was not met it could require
more audits and or adjustments to be made to meet goal.
 This process is called Measures of Success. When completed, if goals are
maintained or exceeded, the facility maintains accreditation. If the plan falls
short of its goal, more may be required of the facility.
 If the survey reveals multiple unsafe practice standards, it could result in a
follow up survey. During the follow up survey ,JCAHO can look at
everything, not just the deficiencies that were found the first time. This can
result in more follow up surveys including one from CMS.
HOSLER, L. (INTERVIEWER) & CODMAN, J. (INTERVIEWEE). (11 -29-2012)
They focus on problems in health care safety and how to solve them.
The goals are specific for each area of patient care.
 Identify patients correctly
 Identify patient safety risks
 Double identifiers
 Patients at risk for suicide
 Improve staff communication
 Report test results
 Use medicines safely
 Prevent mistakes in surgery
()
 Blood thinners, labeling, record home
medications
 Prevent infection
 Hand washing, surgical, urinary
catheters, central lines
JACHO, 2012
 Correct site / site marking,
universal protocol
 Prevent residents from falling
 High risk/ long term care)
 Prevent bed sores
 High risk/ long term care)
 Instituted in 2001.
 These reflect focus areas in which data is collected to help improve
delivery of health care.
 For each core measure there is corresponding accountability criteria
and outcome measures.
 Until recently, there has been four core measure sets for accredited
general medical/surgical hospitals: acute myocardial infarction (AMI),
heart failure, pneumonia, and Surgical Care Improvement Project
(SCIP). Two additional core measure sets will soon be implemented that
relate to perinatal care and a set from the approved complement of
core measure sets.
(ZHANI, 2012)
 Surgical Care Improvement
Project (SCIP) (i.e.: initial
antibiotic timing)
 Acute myocardial infarction (i.e.:
administration of fibinolytic
therapy within 30 minutes)
 Substance use
 Heart failure
 Tobacco treatment
 Hospital – based inpatient
 Venous thromboembolism
psychiatric services
 Pneumonia measures
 Perinatal care
 Immunization
 Stroke
 Children’s asthma care
 Hospital Outpatient
(JACHO, 2012)
department
 I currently work on a medical/surgical unit at West Shore Medical Center
(WSMC) in Manistee. JCAHO influences my nursing practice by providing the
most up-to-date evidence based practices. WSMC is monitored by the Internal
Organization for Standardization (ISO). Although my facility is not JCAHO,
many of JCAHO standards are expected to be taken into consideration for
policies/procedures for the safest and most sufficient patient care.
 My facility adheres very strictly to infection control standards and we follow a
“Wash in, Wash out” policy. We sanitize our hands when we enter a patient
room and sanitize them again on our way out of the room. This is done every
time for every patient.
 I use sterile precautions when starting IVs. If a medication is to be
administered via the IV route, the access site is sterilized.
 It guides my practice by setting standards of care by enforcing guides
such as acceptable abbreviation list, learning/educational material,
evidence based practice information, and patient safety guides.
 Particularly in home hospice care:
 JCAHO guides our practice by providing guidelines on things such as:

Education based on evidence based practices to prevent patient falls in the home

Create and educate patients on their medications

Identify and educate on in home patient safety
 As a nurse it guides our collaboration of care and supervision of an interdisciplinary
team .
 In my current position as a supervisor at a Long Term Acute Care
Hospital JCAHO guides my practice by setting standards that are
evidence based. Part of my responsibility includes monitoring the staff
to make sure that he/she is following current safe practice standards.
 JCAHO is able to visit a facility unannounced at any time so every
member of my team needs to work in a constant state of readiness for
a survey. It is my responsibility to provide in the moment teaching for
staff members that may be practicing outside of those standards.
 Some of those standards we are working on at this time include
infection control, central line associated blood infections, and catheter
associated urinary tract infections.
 I work at the Grand Traverse Pavilions in Traverse City Michigan. This is
a long term care facility. We are not a JCAHO accredited facility.
 The practice standards of the Joint Commission influence my nursing
practice in a nursing home by:
 Bed requirements- this defines the occupancy allotment of the facility
 We have specific isolation rules for residents in isolation. This differs than the
hospitals.
 National Patient Safety Goals pertinent to the perioperative area including
hand washing, patient identification and medication labeling
 Development of the Universal Protocol to ensure the correct procedure is
being done on the correct patient
 Sentinel Event review to process errors and omissions to prevent
reoccurrence
 Surgical Site Infection (SSI) prevention guidelines to ensure proper antibiotic
prophylaxis
 Accreditation Requirements that are recognized and promoted by AORN
 JCAHO is not affiliated with the MDOC
 MDOC utilizes standards of care from the National Commission on
Correctional Health Care (NCCHC) and the National Council on Quality
Assurance (NCQA)
 Although MDOC in not JCAHO accredited, It is important for correctional
nurses to understand these standards to ensure a consistent nursing practice.
 JCAHO helps correctional nurses deliver safe quality health care to inmates.
(MICHIGAN, 2012)
(NCCHC , 2012)
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The Joint Commission (TJC) (2012). History of the joint commission.
Retrieved from, http://www.jointcommission.org/about_us/history.aspx
Michigan.gov (2012). Department of corrections: health care. Retrieved from:
http://www.michigan.gov/corrections/0,4551,7-119-9741_11776---,00.html
National Commission on Correctional Health Care (NCCHC) (2012).
Regulations, Standards and Policies. Retrieved from:
http://www.ncchc.org/pubs/CC/CNP/8_regulations.html
Kusler-Jensen, J.(2009 September). Perioperative Implications of the Joint Commission’s 2009
Accreditation Requirements. AORN Journal (90) 3
JCAHO. (2012). Core Measures. Retrieved from http://www.jointcommission.org
JCAHO, (2012). Universal Protocol. Retrieved from
http://www.jointcommission.org/standardsinformation/up.aspx
JCAHO, (2012). Sentinel Event Policy and Procedures. Retrieved from
http://www.jointcommission.org/SentinelEventPolicyandProcedures/
JCAHO, (2012). Hospital National Patient Safety Goals. Retrieved from www.jointcommission.org
Community Health Centers, Inc. (n.d.) Joint commission on accreditation of healthcare
organizations. Retrieved from http://www.chc-ut.org/Web%20Pages/jcaho.htm
Joint Commission International (JCI) (n.d.) Common questions and answers regarding JCI
accreditation, clinical laboratories, and these standards. Retrieved from
www.jointcommissioninternational.org
Slavin, P. L. (2009) Joint commission survey results. Retrieved from
http://qualityandsafety.massgeneral.org/jcaho/summary_0909.aspx
Tinkoff, G. (2007) Corrective action plans. Retrieved from https://www.socialtext.net/acsdemo-wiki/corrective_action_plans