Hospital Information for the Public

What is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?

The Joint Commission on Accreditation of Healthcare Organizations is the nation’s leading evaluator of healthcare quality. The independent, not-for-profit Joint Commission accredits nearly 20,000 healthcare organizations. The Joint Commission’s mission is to improve the safety and the quality of care provided to the public.

What is accreditation?

Accreditation is a mandatory license evaluation for hospitals in Rhode Island, conducted through an on-site survey by experienced healthcare professionals who gather extensive performance information as the basis for judging compliance with Joint Commission standards. Accreditation surveys usually occur every three years. By complying with accreditation, healthcare organizations demonstrate their commitment to quality care, continuous improvement and public accountability for the care and services they provide.

What are performance reports?

Performance reports provide useful and understandable information about the performance of all healthcare organizations by the Joint Commission.

When did the Joint Commission begin publishing performance reports?

The Joint Commission began releasing performance reports in 1994.

Why does the Joint Commission issue performance reports?

Access to current, accurate and meaningful information helps healthcare consumers; purchasers and providers make informed decisions regarding their healthcare and the quality of care provided. The public release of this information also spurs quality improvement initiatives throughout the healthcare industry.

Should a performance report be the sole reason for choosing-or not choosing- a healthcare organization, like a hospital?

Performance reports are intended to be helpful in making judgements about potential vendors of care. However, they should not serve as the sole basis for any decision. The information contained in the performance reports, and the accreditation process, in general, does not guarantee that a particular individual will receive quality care in a specific healthcare setting at a particular time.

What types of information are available in the performance reports?

Each report includes the healthcare organizations:

• Name and address
• Accreditation date and decision
• Overall evaluation score
• Performance level for key areas evaluated
• Recommendations for improvement, if applicable
• Performance in comparison to other organizations nationally

What the key areas evaluated?

This depends upon the type of healthcare organization being accredited. In hospital accreditation surveys, for example, 45 performance areas encompassing nearly 500 standards are evaluated. Some of the 45 performance areas include:

• Medication use
• Infection control
• Patient rights
• Medical staff qualifications
• Security and safety management
• Education and training of staff

How does the Joint commission grade a healthcare organization?

The Joint Commission does not grade "on the curve", that is to say, the scoring does not indicate a hospital’s ranking in relation to other hospitals. Rather, the score indicates how well a hospital measures up against an absolute standard which reflects the level of performance that every hospital would wish to meet. Healthcare organizations are scored on a scale. The overall evaluation score is based upon a 100-point scale, with 100 being the best.

How does an individual determine how an organization performs in comparison to other organizations?

The Joint Commission provides comparative data in all performance reports to help the user determine whether a score received in a particular area is above or below the national average.

Does a high score guarantee quality patient care?

The Joint commission cannot guarantee quality patient care. The Joint Commission is confident, however, that complying with state-of-the-art healthcare standards improves an organization’s ability to provide quality patient care.

Many performance reports list specific recommendations for improvement. How are these specific areas handled?

In order to remain accredited, an organization must demonstrate compliance with the identified standards within a specified period of time (usually one to six months). Organizations show evidence of compliance either through a written progress report or through a focused return visit by Joint Commission surveyors.

Which scoring areas are the most important?

Areas directly affecting patient care are the most important in determining the overall accreditation decision.

Are performance reports updated?

Yes, performance reports are updated to reflect any changes during the three-year accreditation cycle. Reports are updated, for example, once a recommendation for improvement has been resolved or if an intra-cycle accreditation survey results in any changes to an organization’s accreditation status.

How can you request a performance report?

Anyone can request a performance report by calling the Joint Commission’s Customer Service Center at 630-792-5800, 8AM to 5PM, Central Time, Monday through Friday.