CJCP
Abuse - ANS-Intentional mistreatment that may cause either physical or psychological
injury. See also mental abuse, neglect, physical abuse, sexual abuse.
Accreditation - ANS-Determination by The Joint Commission that an eligible
organization complies with applicable Joint Commission accreditation requirements.
Accreditation Committee - ANS-The committee of The Joint Commission's Board of
Commissioners that is responsible for oversight of its accreditation process.
accreditation contract - ANS-Categories of accreditation that an organization can
achieve based on a Joint Commission survey. These decision categories are as follows
Preliminary Accreditation - ANS-The organization demonstrates compliance with
selected standards in surveys conducted under the Early Survey Policy option.
Accredited - ANS-The organization is in compliance with all applicable standards at the
time of the on-site survey or has successfully addressed all Requirements for
Improvement (RFIs) in an Evidence of Standards Compliance (ESC) within 45 or 60
days following the posting of the Accreditation Survey Findings Report and does not
meet any other rules for other accreditation decisions.
Contingent Accreditation - - ANS-As determined by the Accreditation Committee, the
organization has successfully abated an Immediate Threat to Life (ITL) situation through
direct observation or other method, fails to successfully address all requirements of the
Accreditation with Follow-up Survey decision, shows some evidence of engaging in
possible fraud or abuse, demonstrates patterns or trends of noncompliance at an initial
survey, and/or is not recommended for certification by Centers for Medicare & Medicaid
Services (CMS) after undergoing its first Joint Commission survey to initially achieve
Medicare certification or recognition. In most cases, a follow-up survey in 30 days will
be required to show resolution of the issues that led to the decision. If an organization
receives this decision because it was not recommended for certification by CMS or
demonstrates systemic patterns or trends of noncompliance at an initial survey, the
organization will remain in Contingent Accreditation until the organization can be
recommended for certification or it meets a rule for Preliminary Denial of Accreditation
or Denial of Accreditation.
, Preliminary Denial of Accreditation - ANS-There is justification to deny accreditation to
the organization as evidenced by
- An Immediate Threat to Health or Safety to patients or the public, and/or
- Submission of falsified documents or misrepresented information, and/or
- Lack of a required license or similar issue at the time of survey, and/or
- Failure to resolve the requirements of Contingent Accreditation, and/or
- Significant noncompliance with Joint Commission standards, and/or
- Patients having been placed at risk for serious adverse outcomes due to significant
and pervasive patterns/trends/repeat findings
The decision is subject to review and appeal by the organization prior to the
determination to deny accreditation.
Accreditation with Follow-up Survey - ANS-The organization is not in compliance with
specific standards that require a follow-up survey within 30 days to 6 months. The
health care organization also must successfully address the identified problem area(s)
in an ESC submission.
- Denial of Accreditation - - ANS-The organization has been denied accreditation. All
review and appeal opportunities have been exhausted.
accreditation manual - ANS-A Joint Commission publication consisting of policies,
procedures, and accreditation requirements relating to ambulatory care, behavioral
health care, critical access hospital, home care, hospital, nursing care center,
office-based surgery, and clinical laboratory and point-of-care testing. Organizations
should use the manual that contains the set of accreditation requirements that is most
appropriate to the primary focus or mission of the organization.
accreditation process - ANS-A continuous process whereby organizations are required
to demonstrate to The Joint Commission that they are providing safe, high-quality care,
as determined by compliance with Joint Commission standards, National Patient Safety
Goals, and performance measurement requirements (as applicable). Key components
of this process are an on-site evaluation of the organization by a Joint Commission
surveyor(s) and, where applicable, quarterly submission of performance measurement
data to The Joint Commission.
accreditation survey - ANS-An on-site evaluation of an organization to assess its level of
compliance with applicable Joint Commission accreditation requirements and to make
determinations regarding its accreditation status. The survey includes evaluation of
documentation of compliance provided by organization staff; verbal information
concerning the implementation of standards or examples of their implementation that
Abuse - ANS-Intentional mistreatment that may cause either physical or psychological
injury. See also mental abuse, neglect, physical abuse, sexual abuse.
Accreditation - ANS-Determination by The Joint Commission that an eligible
organization complies with applicable Joint Commission accreditation requirements.
Accreditation Committee - ANS-The committee of The Joint Commission's Board of
Commissioners that is responsible for oversight of its accreditation process.
accreditation contract - ANS-Categories of accreditation that an organization can
achieve based on a Joint Commission survey. These decision categories are as follows
Preliminary Accreditation - ANS-The organization demonstrates compliance with
selected standards in surveys conducted under the Early Survey Policy option.
Accredited - ANS-The organization is in compliance with all applicable standards at the
time of the on-site survey or has successfully addressed all Requirements for
Improvement (RFIs) in an Evidence of Standards Compliance (ESC) within 45 or 60
days following the posting of the Accreditation Survey Findings Report and does not
meet any other rules for other accreditation decisions.
Contingent Accreditation - - ANS-As determined by the Accreditation Committee, the
organization has successfully abated an Immediate Threat to Life (ITL) situation through
direct observation or other method, fails to successfully address all requirements of the
Accreditation with Follow-up Survey decision, shows some evidence of engaging in
possible fraud or abuse, demonstrates patterns or trends of noncompliance at an initial
survey, and/or is not recommended for certification by Centers for Medicare & Medicaid
Services (CMS) after undergoing its first Joint Commission survey to initially achieve
Medicare certification or recognition. In most cases, a follow-up survey in 30 days will
be required to show resolution of the issues that led to the decision. If an organization
receives this decision because it was not recommended for certification by CMS or
demonstrates systemic patterns or trends of noncompliance at an initial survey, the
organization will remain in Contingent Accreditation until the organization can be
recommended for certification or it meets a rule for Preliminary Denial of Accreditation
or Denial of Accreditation.
, Preliminary Denial of Accreditation - ANS-There is justification to deny accreditation to
the organization as evidenced by
- An Immediate Threat to Health or Safety to patients or the public, and/or
- Submission of falsified documents or misrepresented information, and/or
- Lack of a required license or similar issue at the time of survey, and/or
- Failure to resolve the requirements of Contingent Accreditation, and/or
- Significant noncompliance with Joint Commission standards, and/or
- Patients having been placed at risk for serious adverse outcomes due to significant
and pervasive patterns/trends/repeat findings
The decision is subject to review and appeal by the organization prior to the
determination to deny accreditation.
Accreditation with Follow-up Survey - ANS-The organization is not in compliance with
specific standards that require a follow-up survey within 30 days to 6 months. The
health care organization also must successfully address the identified problem area(s)
in an ESC submission.
- Denial of Accreditation - - ANS-The organization has been denied accreditation. All
review and appeal opportunities have been exhausted.
accreditation manual - ANS-A Joint Commission publication consisting of policies,
procedures, and accreditation requirements relating to ambulatory care, behavioral
health care, critical access hospital, home care, hospital, nursing care center,
office-based surgery, and clinical laboratory and point-of-care testing. Organizations
should use the manual that contains the set of accreditation requirements that is most
appropriate to the primary focus or mission of the organization.
accreditation process - ANS-A continuous process whereby organizations are required
to demonstrate to The Joint Commission that they are providing safe, high-quality care,
as determined by compliance with Joint Commission standards, National Patient Safety
Goals, and performance measurement requirements (as applicable). Key components
of this process are an on-site evaluation of the organization by a Joint Commission
surveyor(s) and, where applicable, quarterly submission of performance measurement
data to The Joint Commission.
accreditation survey - ANS-An on-site evaluation of an organization to assess its level of
compliance with applicable Joint Commission accreditation requirements and to make
determinations regarding its accreditation status. The survey includes evaluation of
documentation of compliance provided by organization staff; verbal information
concerning the implementation of standards or examples of their implementation that
