Earning the Gold Seal of Approval from the Joint Commission

Revised September 2022

Complying with the latest regulations will always be a critical priority for healthcare compliance professionals. But earning approval from The Joint Commission, the recognized global leader for health care accreditation, is growing in importance across healthcare organizations, including hospitals, physician group practices, surgery centers, and other treatment facilities. 

This accreditation, known as The Gold Seal of Approval®, acknowledges an organization’s dedication to providing quality care and services to patients. Some states require health care organizations to be accredited by the Commission in order to participate in particular insurance programs.  

If a healthcare organization is accredited by The Joint Commission, it may be deemed to exceed Centers for Medicare and Medicaid (CMS) requirements, along with state law requirements. Additionally, with the public’s attention increasingly focused on becoming informed consumers, earning accreditation also offers organizations a competitive edge.   

Meet the Joint Commission 

The Joint Commission is an independent, not-for-profit organization based in Illinois. Founded more than 65 years ago, the Commission provides an unbiased assessment of a health care organization’s quality achievements in patient care and safety. 

It offers the following accreditation programs: 

  • Ambulatory Care Accreditation 
  • Behavioral Health Care Accreditation 
  • Critical Access Hospital Accreditation 
  • Home Care Accreditation 
  • Hospital Accreditation 
  • Laboratory Services Accreditation 
  • Nursing Care Center Accreditation 
  • Office-Based Surgery Accreditation 

In addition, The Joint Commission offers 20 different certifications for a variety of clinical programs and services. 

Understand the Accreditation Process 

The Commission’s standards set expectations for an organization’s performance that are reasonable, achievable, and measurable. Its on-site surveys are rigorous and are customized for each organization and its efforts to improve patient outcomes. And the start of a survey is usually unannounced. 

During an on-site survey, Commission surveyors perform their evaluation by: 

  1. Tracing the care delivered to patients, residents, or individuals served 
  1. Reviewing the information and documentation provided by the organization 
  1. Observing and interviewing staff and, when appropriate, patients 

The Commission provides a Summary of Survey Findings Report at the conclusion of the on-site survey, with a final accreditation decision made at a later date. Surveyors could recommend: 

  1. Preliminary accreditation 
  1. Accreditation 
  1. Accreditation with follow-up survey 
  1. Preliminary denial of accreditation 
  1. Denial of accreditation 

An organization’s accreditation is continuous as long as it has a full, unannounced survey within 36 months of the previous survey and it meets all accreditation-related requirements. 

Benefits from Accreditation 

The Gold Seal of Approval is a way to let medical professionals, government regulators, and patients know that an organization stands for quality care, and that it’s always seeking ways to identify known or unknown risks to patient safety. 

For example, healthcare organizations that want to participate in Medicare have to be certified to have met specific CMS quality-related standards. If the organization is accredited by The Joint Commission, CMS will have deemed the entity to have met or exceeded these requirements. That means the organization is not subject to Medicare’s survey and certification process because it has already gone through the Commission’s survey process. 

Additionally, being Commission-accredited may allow the organization to be exempt from meeting state law survey or quality or requirements. Here you want to be sure and check your state laws to see if they exempt entities accredited by The Joint Commission. 

In what other ways can an organization benefit from Joint Commission accreditation? 

  • It can earn various Joint Commission certifications for continued improvement and maintaining performance excellence 
  • It can connect with other like-minded organizations to collaborate on issues affecting the quality and safety of patient care 
  • It can attract more qualified personnel who prefer to serve in a prestigious environment 

Earning Accreditation Means Maintaining Compliance 

Earning the Joint Commission’s Gold Seal of Approval depends on a strong culture of compliance. Organizations that are challenged to manage compliance, or effectively demonstrate compliance, are unlikely to meet the Joint Commission’s rigorous standards. (Read more about Compliance Culture on the YouCompli blog.) 

A culture of compliance is a commitment throughout all levels of an organization to do the right thing and do things right.  When an organization has a strong culture of compliance, there is a spillover effect to obtaining and maintaining Commission accreditation.  Employees see their leaders ensuring the organization is maintaining compliance with elevated standards. Additionally, they see their leaders making business decisions based on organizational policy requirements.  The end result is actions being taken that demonstrate leading by example and modeling that behavior to employees. 

The Gold Seal of Approval accreditation is an important acknowledgment of an organization’s dedication to providing quality care and services to patients. The effort to earn this accreditation is certainly significant, but the payoff in terms of reputation, recruiting and deeming status is worth the effort. Not only that, the process of earning accreditation can help you uncover opportunities to further shape your culture of compliance so that a mindset of always doing the right thing permeates all levels of your organization. All of that is good for the long-term health of your business – and your patients.  

The accreditation process requires significant metrics to demonstrate the effectiveness of your compliance program, YouCompli can help you verify that you took the proper steps to comply with the regulations that apply to you. Find out how.  

Jerry Shafran is the founder and CEO of YouCompli. He is a serial entrepreneur who builds on a solid foundation of information technology and network solutions. Jerry launches, manages, and sells software and content solutions that simplify complex work. His innovations enable professionals to focus on their core business priorities.

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