Accreditation & Certification: Interview with an Expert from The Joint Commission

“The Joint Commission has exclusively focused on the healthcare industry for 70 years. Our mission is to improve healthcare for the public, by evaluating and inspiring healthcare organizations to excel in providing safe and effective care of the highest quality and value.”

Chad Larson, Executive Director of the Hospital Accreditation Program at The Joint Commission

The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the US. As the nation’s oldest and largest standards-setting accrediting body in healthcare, its Gold Seal of Approval has fittingly become the gold standard for healthcare facilities. The Joint Commission’s 21-member Board of Commissioners includes physicians, administrators, nurses, quality experts, educators, and advocates. Together, they employ a surveyor force of approximately 1,000 people.

Accreditation is awarded after a healthcare facility completes an on-site survey. These surveys are carried out by a specially-trained Joint Commission surveyor, or team of surveyors, to assess a facility’s compliance to rigorous standards around care quality and patient safety. A survey’s findings may be provided through a SAFER Matrix (Survey Analysis For Evaluating Risk), which helps organizations prioritize and focus on corrective actions.

“The Joint Commission is the only accreditation organization with the depth and breadth of standards writing and survey experience that spans the entire continuum of healthcare,” Larson says. “Our standards exceed many national requirements and are developed in concert with healthcare professionals, the public, and many key stakeholders and professional associations.”

Larson graciously shared his perspective on The Joint Commission’s methods and objectives, as well as the benefits of accreditation.

Meet the Expert: Executive Director Chad Larson, MBA

Chad Larson

Chad Larson is the Executive Director of the Hospital Accreditation Program at The Joint Commission. Larson holds a Master of Business Administration (MBA) from Keller Graduate School of Business (Chicago, IL) with an emphasis in Health Services Administration, and a Bachelor of Science (BS) in Kinesiology from Northern Illinois University (DeKalb, IL) with an emphasis in Preventative and Rehabilitative Exercise Science.

Larson is a 15-year veteran of The Joint Commission, having previously served as Director of Business Operations. He also served as a Malcolm Baldrige National Quality Award examiner, which offers the highest level of recognition for performance excellence that a US organization can achieve. Larson is a member of the American College of Healthcare Executives (ACHE).

How Does The Joint Commission Evaluate Programs and Organizations?

The Joint Commission’s survey process is data-driven, patient-centered, and focused on providing actual care processes, using ‘tracer methodology’ as a risk-reduction strategy. Tracing the patient’s experience, which involves observing services provided by various caregivers within the organization, as well as hand-offs between departments and units, is a survey process uniquely developed and used by The Joint Commission.

The core mission of The Joint Commission is to strengthen efforts around patient safety, risk management, and quality of care. The survey process can, in and of itself, be instructive for a healthcare facility and its administrators, as preparing for inspection provides a framework for organizational structure and management. While accreditation is a voluntary procedure, an estimated 75 percent of hospital organizations have chosen to pursue it.

Critically, Joint Commission surveyors are employees of the organization. This allows for a more robust education and personnel evaluation process than utilizing a traditional volunteer surveyor approach. All clinician surveyors have a minimum of 20 years of professional experience, and many maintain dual employment in hospitals and outpatient settings. And the collaboration doesn’t end with the survey process, either.

“The support that The Joint Commission provides to healthcare organizations remains unmatched,” Larson says. “The dedicated support organizations receive to understand and maximize the benefits of Joint Commission accreditation are instrumental in the high remarks we receive. All organizations receive dedicated support staff to navigate them throughout the customer lifecycle. Additionally, standards interpretation assistance is provided to help better understand the intent and compliance with accreditation requirements.”

What are the Benefits of Joint Commission Accreditation?

The benefits of Joint Commission accreditation are many: it strengthens community trust of a healthcare facility, provides a competitive edge in the marketplace, and enhances staff recruitment.

Accreditation can also provide deeming authority for Medicare certification, easing the burden of redundant federal and state surveys, and some insurers may even require accreditation as a prerequisite for reimbursement.

A 2011 meta-analysis of peer-reviewed studies found that accreditation programs significantly improve clinical outcomes and quality of care. But accreditation is not easy, nor is it free. Annual fees for a facility can amount to tens of thousands of dollars, and, according to one case study, account for only a fraction of the overall cost of accreditation. The Joint Commission helps facilities recoup these costs by offering value-add resources to accredited organizations.

“The Joint Commission is a global improvement organization that focuses not just on providing an educative and collaborative survey experience, but also a commitment to providing quality improvement tools and resources to healthcare organizations as part of the annual fee,” Larson says.

“Some of these tools include resources, modules, portals, and specific standards and performance measure requirements that are specifically aimed at reducing some of the most common hospital-acquired infections and/or conditions that plague hospitals today. The Joint Commission also provides multiple value-added resources back to organizations based on patterns and trends found during the on-site survey process, as well as self-reported adverse events. These dashboards are geared toward assisting organizations in facilitating ongoing discussions within their own ongoing quality improvement work.”

Not everyone has been convinced it’s a good deal: a 2018 article in the Journal of the American Medical Association (JAMA) stated that accredited hospitals may not necessarily provide better care than those undergoing other forms of oversight, such as state surveys. But even with that negative slant, the article’s authors still emphasized the importance of accreditation as a cornerstone of ensuring a basic level of quality.

Fittingly for an entity dedicated to quality and oversight, The Joint Commission submitted a rebuttal that pointed out factual errors, methodology errors, and analytical errors in the article.

The data is on The Joint Commission’s side, too. The fully published literature on Joint Commission accreditation is overwhelmingly positive: more than 100 published studies speak to the positive impact that The Joint Commission has had on quality in healthcare facilities. It remains by far the most advanced, vetted, and professional accrediting organization in the healthcare ecosystem.

The Bottom Line: The Enduring Importance of The Joint Commission in Healthcare

The Joint Commission is a large and evolving entity. It regularly updates its standards, which address a broad spectrum of healthcare topics. The Joint Commission monitors how it collects data, and uses that data to improve itself. Standards need to be revised for a whole host of reasons, from changing policy priorities, to the evolution of technology, to specific issues around quality and safety.

“Joint Commission staff continuously reviews literature and attends conferences and workgroups to keep aware of major scientific studies that might justify changes to our standards and ensure that they remain relevant,” Larson says. “We also annually review reports from major safety organizations (e.g., ECRI) on top quality and safety concerns.”

In addition to accreditation, The Joint Commission offers specialized certifications in nearly 100 clinical categories across the continuum of care. For healthcare facilities, certification in one area can lead to a reduction in variability and improvement in outcomes through the implementation of very specific requirements and performance measure reporting and monitoring.

It’s hard to overstate just how much The Joint Commission does within the healthcare sector. The Joint Commission also offers a wealth of resources to help facilities prepare for and sustain accreditation and certifications. The Joint Commission’s Center for Transforming Healthcare delivers programs, products, and services to help those facilities continue to transform into high- reliability institutions where zero harm is the norm.

And, through The Joint Commission’s journal, newsletters, and Quick Safety guidelines, it provides advisories to the public on important healthcare topics: the optimal use of telehealth; reducing health disparities for LGBTQ patients; and promoting the psychosocial well-being of healthcare staff during crises such as Covid-19.

“Because of worsening maternal morbidity and mortality rates in the US, The Joint Commission recently released requirements in perinatal care to improve the quality and safety of care provided to women during all stages of pregnancy and postpartum (the US ranks 65th among industrialized nations in terms of maternal death),” Larson says. “Accreditation topics under development or review include workplace violence, telehealth, information technology, and healthcare disparities.”

Accreditation is a critical step in ensuring the trust and quality of any large, public-facing institution. There will continue to be healthcare organizations that choose to seek accreditation through The Joint Commission, as well as those that do not.

But the best healthcare organizations in the United States will increasingly fall into the former category, and the latter category is dwindling. Continued evolution in the accreditation of America’s healthcare facilities will bring about better patient outcomes, boosted care quality, and a reduction of healthcare inequities.

Matt Zbrog
Matt Zbrog

Matt Zbrog is a writer and researcher from Southern California. Since 2018, he’s written extensively about emerging issues in healthcare administration and public health, with a particular focus on progressive policies that empower communities and reduce health disparities. His work centers around detailed interviews with researchers, professors, and practitioners, as well as with subject matter experts from professional associations such as the American Health Care Association / National Center for Assisted Living (AHCA/NCAL) and the American College of Health Care Executives (ACHCA).

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