Hospital Information for the Public

How does the accreditation process work?

To earn and maintain accreditation, a hospital must undergo an on-site survey by a Joint Commission survey team at least every three years. The objective of the survey is not only to evaluate the hospital, but also to provide education and guidance that will help the staff continue to improve the hospital's performance.

The Team

Survey teams usually include three health care professionals--a physician, a nurse and a hospital administrator--who have senior management level experience in health care organizations. Depending on the volume and range of services offered by the hospital, additional surveyors with particular expertise may be added to the team. The surveyors are selected from the Joint Commission's cadre of over 500 surveyors. All Joint Commission surveyors are extensively trained before they are sent into the field, and all receive continuing education to keep them up-to-date on advances in quality-related performance evaluation.

The Survey

The survey team spends several days at the hospital observing activities, interviewing patients and staff, and reviewing documents. The team spends a significant amount of time on patient units, observing care as it is carried out. The team may track a patient through his or her hospital stay--in person and through medical records--to find out how the hospital's systems and processes work in supporting patient care. The surveyors do not judge directly whether the care given to a specific patient is good or bad, right or wrong. Rather, they determine what activities are carried out, how well they are performed and, where possible, the resulting effects or outcomes for patients of various types. The surveyors use scoring guidelines to assist them in making judgments about standards compliance in specific performance areas.

The Evaluation

Different members of the survey team may look at specific areas or departments of the hospital, according to their expertise. But they work together closely at every step, integrating their findings to reach conclusions about hospitalwide performance.

At the end of the survey, the team scores the hospital on how well it meets the standards in the Accreditation Manual for Hospitals (for an explanation of the standards, see below). Related standards are grouped into performance areas, each of which is scored. Finally, the performance area scores are combined to produce the hospital's overall score. The overall score is based upon 100. In almost all cases, that score, along with related performance considerations, determines the category of accreditation. After receiving accreditation, the hospital is required to remain in compliance with all standards during its three-year accreditation cycle.