Summary: How to become accredited. What is the process required to achieve TJC accreditation? What does TJC accreditation mean?

TJC accreditation is a national recognition for a healthcare organization who has complied with all of the standards set forth by TJC. TJC stands for The Joint Commission. They used to be referred to as JCAHO which was the Joint Commission on Accreditation of Healthcare Organizations. TJC is one of the few national organizations to be recognized by CMS for accreditation services. TJC accreditation is difficult to obtain and carries a prestige which sets apart those organization who are accredited from those who aren’t. It also provides a competitive advantage as consumers are becoming more and more astute and ,generally speaking, if they have a choice between and accredited organization and a non-accredited organization, accreditation will be chose. Accreditation gives a level of confidence to consumers that the organization strives for and has attained a high level of both quality and patient satisfaction.

How to Become Accredited:

What do the standards accomplish?

  1. An objective evaluation process to assist health care organizations measure, assess, and improve performance
  2. Focus on patient and organizational functions required to provide safe high quality care
  3. Set expectations that are reliable and measurable

What is involved in the survey process?

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The TJC evaluates an organization’s performance with the intent of providing continuous improvement in terms of patient outcomes. The survey process is based upon:

  1. Patient tracer methodology in which a patient is traced through the continuum of care as he progresses through the health care system.
  2. Helpful information provided by TJC both written and verbal
  3. Observations by surveyors first hand and on site
  4. Documentation review

All TJC surveys are unannounced meaning the organization must be in a constant state of readiness. The unannounced visit no longer exists. For these unannounced visits, the organization had a tendency to “cram” for the survey just prior to the TJC arrival rather than eating, sleeping, and breathing the accreditation way of life. If you practice something enough, it becomes a habit and that is the intent of these surveys. Surveys occur generally between 18 and 36 months apart.

The decision as to whether or not to grant accreditation is based upon how well the organization provides excellent patient care in a safe environment.

There are 6 decisions which can be reached at the close of a survey:

  1. Preliminary accreditation
  2. Accreditation
  3. Accreditation with Follow-Up survey
  4. Contingent Accreditation
  5. Preliminary Denial of Accreditation
  6. Denial of Accreditation

TJC accreditation is not only difficult to achieve but provides an immense feeling of satisfaction upon being granted “Accreditation”. The TJC website has a listing of all organizations who have achieved accreditation. If you require a TJC consultant to assist you with all of your TJC accreditation consulting needs, please contact us.

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