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7 Steps to Accreditation by The Joint Commission

By CME Corp Staff | November 28, 2023

We live in a society that, in many ways, standardizes and measures commitment to excellence through accreditation. Organizations across industries seek accreditation to publicly show their commitment to quality within their landscape.

Facilities within the healthcare industry are no different.

Healthcare organizations voluntarily seek out accreditation to demonstrate their commitment to quality patient care and continuous improvement of their services.

Within the healthcare environment, there are five primary accrediting agencies. These agencies are independent and not-for-profit.

  • URAC – Utilization Review Accreditation Commission
  • NCQA – National Committee for Quality Assurance
  • TJC – The Joint Commission
  • CARF – Commission on Accreditation of Rehabilitation Facilities
  • COA – Council on Accreditation

Of these regulatory agencies, The Joint Commission or TJC is the oldest and one of the most widely recognized in the United States, having been established in 1951. According to their website 80% of US hospitals are accredited by The Joint Commission.

Accreditation or certification by The Joint Commission is a quality symbol that shows an organization’s commitment to meeting performance standards.

In this article we will discuss accreditation by the Joint Commission. Specifically, we will cover:

What is The Joint Commission?

The Joint Commission is an independent regulatory agency that sets quality and safety standards for healthcare organizations. Their objective is to help medical facilities and programs measure, assess, and improve patient care.

The standards themselves are comprehensive, covering many aspects of healthcare delivery, from patient care, medication safety, infection control, and emergency management to specific standards for medical equipment.

TJC also assesses compliance with these standards through on-site evaluations, surveys, and inspections.

The Joint Commission currently offers accreditation to:

  • Ambulatory Healthcare Facilities
  • Behavioral Healthcare Facilities
  • Critical Access Hospitals
  • Home Care
  • Hospitals
  • International Healthcare Organizations
  • Laboratory Services
  • Nursing and Rehabilitation Centers

In addition to accreditation, TJC also offers certificate programs for specific programs or services. These certifications demonstrate excellence and specialized expertise in separate areas within accredited organizations.

  • Disease Specific Care (i.e., stroke care or cardiac care)
  • Healthcare Staffing Services
  • Advanced Certification
  • International Certification

How Long Does It Take to Get Joint Commission Accreditation?

The accreditation preparation period can take anywhere from four to six months and includes 2-5 days of rigorous on-site evaluation, followed by two weeks to a month before the accreditation decision is rendered.

Accreditation requires time and money. The Joint Commission accreditation process involves a thorough evaluation of a healthcare organization’s policies, procedures, practices, and performance outcomes. Surveys focus on patient safety, observed clinical excellence, and adherence to evidence-based practices.


The Joint Commission Accreditation Process

The goal of seeking accreditation from The Joint Commission is to demonstrate a healthcare organization’s commitment to promoting safe and effective care as well as to continuously improving the quality of the healthcare offered to the community.

To ensure that a medical facility has attained this goal, The Joint Commission follows a comprehensive and structured evaluation process. While specific details of the process will vary based on the healthcare organization pursuing accreditation, the general process is comprised of seven steps.


A healthcare organization seeking accreditation must apply to The Joint Commission expressing their interest and intent. The application requests information about the organization’s size, services provided, and its current compliance with applicable laws and regulations.

Pre-Survey Assessment

During the pre-survey assessment, a TJC representative reviews policies, procedures, medical records, and other relevant documentation to evaluate the organization’s readiness for the accreditation survey.

On-Site Survey

Over a two-to-five-day period, a team of Joint Commission surveyors, consisting of healthcare professionals and experts, visits the organization to survey its compliance with Joint Commission standards. For this survey, the team will interview staff, review patient care processes, observe operations, and assess the physical environment.

Findings and Recommendations

At the conclusion of the on-site survey the healthcare organization will receive a report summarizing TJC’s findings, observations, and recommendations. Included in the report is content related to areas of compliance, opportunities for improvement, and problem resolution requirements (if necessary).

Performance Improvement

Healthcare organizations will then develop and implement a performance improvement plan that addresses deficiencies or problem areas noted in the survey report. A comprehensive improvement plan will identify clear steps to be taken to resolve identified issues, the timeline for resolution, and the professionals responsible for the success of the corrective action plan. A document showing evidence of compliance with all applicable standards must be submitted to TJC within a defined period.

Decision on Accreditation

The Joint Commission Accreditation Committee will review all assessment evaluations and survey findings before making the decision to award accreditation. Consideration is given to the organization’s overall compliance with Joint Commission standards, the effectiveness of the corrective action plan, and any outstanding issues.

Accreditation Status and Follow-Up

Following the decision by The Joint Commission, the healthcare organization is notified of its accreditation status: full accreditation, provisional accreditation, or denial of accreditation.

Apart from Laboratory, accreditations are valid for three years. Laboratory accreditation and certificates are valid for two years.

If accredited, the organization is required to maintain compliance with standards and participate in on-going performance monitoring and improvement activities. Periodic, sometimes unannounced, re-survey visits are conducted to ensure continuous adherence to accreditation requirements.

Hospitals, home care, or behavioral health facilities accreditation requirements may include additional steps or variations within a step.

Visit The Joint Commission website for comprehensive guidelines and resources to help navigate the accreditations process successfully.


Benefits of Joint Commission Accreditation

In addition to national recognition of a commitment to provide safe, effective, and quality patient care, there are many more benefits of accreditation through The Joint Commission.

Accreditation is often essential to contracts.

Accreditation can

  • be a condition of reimbursement for insurers or other third-party payors,
  • show that the organization meets or exceeds Medicare/Medicaid requirements, and
  • may reduce liability insurance costs.

Accreditation is a mark of quality for patients

Accreditation can offer a competitive advantage in the community, it;

  • offers assurance the organization is current with healthcare regulations,
  • may increase patient satisfaction ratings and
  • ensures higher levels of confidentiality for protected health information.

Accreditation ensures commitment to quality

To maintain accreditation, healthcare organizations commit to excellence in quality, accountability, patient safety, and to support continuous quality improvements.

For the business side of healthcare, accreditation offers quality in the form of a framework for organizational structure and management, in addition to standardization and consistency for processes across the organization.


Accreditation by The Joint Commission is highly regarded and widely sought.

It signifies that a healthcare organization is dedicated to offering high-quality, effective, and safe patient care.

It demonstrates that a healthcare organization meets or exceeds nationally recognized Joint Commission standards and best practices.

It gives patients and caregivers confidence that the accreditation process is rigorous. They can be assured that organizations who have been accredited are able to safeguard patient well-being and safety.


How CME Corp Can Help with Accreditation by The Joint Commission

CME Corp can ensure that healthcare organizations purchase healthcare equipment that meets or exceeds Joint Commission standards for medical equipment and remain in compliance with TJC required annual inspections of that medical equipment.

Over four decades of experience as a medical equipment distributor has given CME Corp. the opportunity to develop and maintain relationships with leading medical equipment manufacturers. Our experts can, and will, help you choose the best equipment for your needs and your budget.

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TJC requires all medical equipment within a facility receive documented annual preventative maintenance. For some hospital systems with multiple non-acute care facilities spread across the community this can put a strain on biomed teams supporting the hospitals.

CME Corp.’s Biomedical Technicians are strategically located throughout the U.S., ready to supplement your in-house biomedical team to ensure the organization has achieved 100% equipment PM compliance.

Give us a call to set-up an annual maintenance schedule 800-338-2372 or email us at repair@cmecorp.com .

About CME: With two corporate offices and 35+ service centers, CME Corp is the nation’s only equipment focused medical equipment distributer. We are the premier source for more than 2 million healthcare equipment products, from more than 2,000 manufacturers.

Our Turnkey logistics and biomedical services allow us to help healthcare facilities nationwide reduce the cost of the equipment they purchase, make their equipment selection, and schedule delivery, installation, and maintenance without impacting patient care. From medical equipment purchases to renovations and new facility construction CME Corp is your partner for seamless capital medical equipment purchases, delivered on time and in budget.

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