Joint Commission Hospital Standards

The hospital submits information to Joint Commission as required.

The hospital must submit required data and information to The Joint Commission in a timely manner to maintain accreditation.

The hospital provides accurate information throughout the accreditation process.

The hospital is required to provide accurate information to The Joint Commission throughout the accreditation process and is prohibited from falsifying records.

The hospital reports any changes in the information provided in the application for accredita...

The hospital must notify The Joint Commission within 30 days of significant organizational changes and immediately upon notice of loss of deemed status from CMS.

The hospital permits the performance of a survey at Joint Commission's discretion.

The hospital must permit The Joint Commission to conduct surveys at its discretion.

The hospital selects and uses performance measures from among those available that are releva...

The hospital must select and report relevant performance measures to The Joint Commission to meet ORYX requirements.

The hospital allows Joint Commission to review the results of external evaluations from publi...

The hospital must provide The Joint Commission with access to official records and reports from other licensing or reviewing bodies upon request.

Applicants and accredited hospitals do not use Joint Commission employees to provide accredit...

Hospitals are prohibited from using Joint Commission employees for accreditation-related consulting services.

The hospital accepts the presence of Joint Commission surveyor management staff or a Board of...

The hospital must allow Joint Commission management or Board members to observe on-site surveys.

The hospital accurately represents its accreditation status and the programs and services to...

The hospital must accurately represent its accreditation status and the specific services covered by that accreditation in all advertising.

The hospital notifies the public it serves about how to contact its hospital management and J...

The hospital must inform the public how to contact hospital management and The Joint Commission to report concerns regarding patient safety and quality of care.

Any individual who provides care, treatment, and services can report concerns about safety or...

The hospital must educate staff and medical staff on their right to report safety or quality concerns to The Joint Commission without fear of retaliation or disciplinary action.

The hospital provides care, treatment, services, and an environment that pose no risk of an “...

The hospital is required to maintain an environment and provide services that do not pose an immediate threat to the health or safety of patients.

The hospital has a comprehensive emergency management program that utilizes an all-hazards ap...

The hospital must maintain a written, comprehensive, all-hazards emergency management program that includes leadership accountability, risk assessment, and preparedness activities.

The hospital conducts a hazard vulnerability analysis utilizing an all-hazards approach.

The hospital must conduct and document a facility-based hazard vulnerability analysis using an all-hazards approach to identify and prioritize potential threats.

The hospital develops an emergency operations plan based on an all-hazards approach.

The hospital must maintain a written all-hazards emergency operations plan that includes procedures for surge capacity, evacuation, sheltering, and resource management.

The hospital has a communications plan that addresses how it will initiate and maintain commu...

The hospital must maintain a communications plan that includes contact lists, reporting procedures, and methods for sharing patient information during emergencies.

The hospital has a staffing plan for managing all staff and volunteers during an emergency or...

The hospital must develop a staffing plan to manage personnel and volunteers during emergency incidents, including methods for contact and role integration.

The hospital has a plan for providing patient care and clinical support during an emergency o...

The hospital must have procedures for sharing patient information and transferring patients to other facilities to maintain continuity of care during emergencies.

The hospital has a plan for safety and security measures to take during an emergency or disas...

The hospital must implement a system to track the location of staff, volunteers, and patients during emergency events, including relocations or evacuations.

The hospital has a plan for managing resources and assets during an emergency or disaster inc...

The hospital must maintain a plan for tracking, monitoring, and replenishing essential resources and assets during and after an emergency incident.

The hospital has a plan for managing essential or critical utilities during an emergency or d...

The standard addresses a hospital plan for maintaining essential or critical utility systems during an emergency or disaster incident.

The hospital has a continuity of operations plan.

The standard addresses a hospital continuity of operations plan for maintaining essential business functions and leadership authority during disruptions.

The hospital has an emergency management education and training program.

The standard addresses hospital emergency management education and training for staff, arranged-service personnel, and volunteers.

The hospital plans and conducts exercises to test its emergency operations plan and response...

The standard addresses hospital exercises to test emergency operations plans and response procedures, including documentation of exercises and incidents.

The hospital evaluates its emergency management program, emergency operations plan, and conti...

The standard addresses hospital review of emergency exercises, disaster incidents, after-action reports, improvement plans, and periodic updates to emergency management documents.

The hospital has the necessary staff to support the care, treatment, and services it provides.

The standard addresses competency of administrative and technical staff in hospital food and dietetic services.

The hospital determines how staff function within the organization.

The standard addresses current licensure, certification, registration, primary source credential verification, and documentation for staff who provide care, treatment, and services.

The hospital defines and verifies staff qualifications.

The standard addresses defining staff qualifications by job responsibility, including references to infection control, laboratory, rehabilitation, interpreter, and respiratory care qualifications.

The hospital provides orientation, education, and training to their staff.

The standard addresses hospital staff orientation, ongoing competency training, annual emergency services readiness training, documentation, and use of QAPI findings to inform training needs.

The hospital evaluates staff competence and performance.

The standard requires initial and periodic assessment and documentation of hospital staff competence according to policy, law, and regulation.

The hospital has a hospitalwide infection prevention and control program for the surveillance...

The hospital must maintain a comprehensive infection prevention and control program that includes surveillance, staff training, and standardized policies for device reprocessing.

The hospital’s governing body is accountable for the implementation, performance, and sustain...

The hospital's governing body is responsible for providing the resources and oversight necessary to ensure the infection prevention and control program is effective and sustainable.

The hospital implements its infection prevention and control program through surveillance, pr...

The hospital must implement active surveillance, outbreak management, and staff health protocols to prevent the transmission of infectious diseases.

The hospital plans for continuity of its information management processes.

The hospital must maintain policies and procedures to ensure the availability and security of medical records during emergencies and system interruptions.

The hospital protects the privacy and confidentiality of health information.

The hospital must implement policies to protect patient health information and ensure disclosures are authorized by law or patient consent.

The hospital maintains the security and integrity of health information.

The hospital must maintain written policies to ensure the security, integrity, and controlled access of health information.

The hospital records health information in standardized formats.

The hospital must use standardized terminology, definitions, and abbreviations in medical documentation to ensure consistency.

The hospital retrieves, disseminates, and transmits health information in useful formats.

The hospital must maintain a system for coding and indexing medical records to ensure timely access to patient information.

For hospitals that use Joint Commission accreditation for deemed status purposes:

The hospital must maintain operational electronic notification systems to exchange patient health information with other providers for care coordination.

The governing body is ultimately accountable for the safety and quality of care, treatment, a...

The governing body is responsible for the hospital's legal conduct, medical staff oversight, grievance processes, and quality assessment programs.

The hospital has an organized medical staff that is accountable to the governing body.

The hospital must maintain an organized medical staff that is accountable to the governing body for the quality of patient care.

Leaders establish priorities for performance improvement.

The hospital must implement a data-driven quality assessment and performance improvement program to enhance patient safety and outcomes.

The hospital complies with law and regulation.

The hospital must operate in accordance with all applicable laws and licensure requirements and maintain specific records for blood components.

For hospitals that use Joint Commission accreditation for deemed status purposes:

The hospital must maintain a utilization review plan and committee to ensure the medical necessity of services provided to Medicare and Medicaid patients.

For hospitals that use Joint Commission accreditation for deemed status purposes:

The hospital must maintain an institutional plan that includes an annual operating budget and a three-year capital expenditure plan.

The hospital effectively manages its programs, services, sites, or departments.

The hospital must assign qualified leadership to oversee specific clinical programs, services, and departments.

The hospital has policies and procedures that guide and support patient care, treatment, and...

The hospital must develop and implement policies to guide patient care, including medication safety and surgical standards.

The hospital provides services that meet patient needs.

The hospital must provide services that meet patient needs, including nursing, emergency, laboratory, and surgical care.

Care, treatment, and services provided through contractual agreement are provided safely and...

The hospital must ensure that services provided through contractual agreements are safe, effective, and compliant with regulations.

The hospital safely manages pharmaceutical services.

The hospital must procure, store, control, and distribute drugs and biologicals in accordance with laws and standards.

The pharmacy is a resource for medication-related information.

The pharmacy must provide professional staff with access to information regarding drug therapy, interactions, and administration.

The hospital selects and procures medications.

The hospital must maintain a formulary that includes medication strength and dosage, accessible to those managing medications.

The hospital safely stores medications.

The hospital must safely store medications, including controlled substances and radiopharmaceuticals, to prevent diversion.

Medication orders are clear and accurate.

The hospital must ensure medication orders are clear, accurate, and documented by authorized practitioners.

The hospital safely prepares medications.

The standard addresses pharmacist supervision, sterile compounding policies, staff competency, compounding environments, storage, labeling, quality assurance, and radiopharmaceutical preparation oversight.

The hospital safely administers medications.

The standard addresses medication administration under law, practitioner orders, standards of practice, medical staff policies, and patient or caregiver self-administration procedures.

The hospital responds to actual or potential adverse drug events, significant adverse drug re...

The standard addresses hospital policies and processes for reporting and evaluating adverse drug events, adverse drug reactions, medication incompatibilities, and medication administration errors.

The hospital establishes antibiotic stewardship as an organizational priority through support...

The standard addresses leadership, coordination, documentation, training, guideline adherence, and tracking for a hospitalwide antibiotic stewardship program.

Medical staff bylaws address self-governance and accountability to the governing body.

The standard specifies required medical staff bylaw content for governance, membership, credentialing, privileging, examinations, committees, and fair hearing processes.

Neither the organized medical staff nor the governing body may unilaterally amend the medical...

The standard addresses limits on unilateral amendment of medical staff bylaws and processes for communication, conflict management, and urgent provisional amendments.

For hospitals that use Joint Commission accreditation for deemed status purposes:

Addresses conditions for separately accredited hospitals in a multihospital system to establish or opt out of a unified and integrated medical staff.

There is a medical staff executive committee.

Addresses the existence, composition, attendance, bylaw conformity, and governing body recommendations of the medical staff executive committee.

The organized medical staff oversees the quality of patient care, treatment, and services pro...

Addresses organized medical staff responsibility for care quality, privileges, patient safety, histories and physicals, emergency care policies, and selected radiology and nuclear medicine staff qualifications.

The management and coordination of each patient’s care, treatment, and services is the respon...

Addresses admission recommendations, continuous physician availability, and practitioner responsibility for Medicare patient care within privileges and licensure.

In hospitals participating in a professional graduate education program(s), the organized med...

Hospitals participating in professional graduate education programs must define medical staff supervision, role descriptions, order-writing limits, communications, and compliance with review committee citations.

The organized medical staff leads and participates in organizationwide performance improvemen...

The organized medical staff must lead and participate in performance improvement activities addressing care quality, patient safety, pain management, opioid prescribing, records, and practitioner competence.

Prior to granting a privilege, the hospital determines if the resources necessary to support...

Before granting a privilege, the hospital must determine whether sufficient space, equipment, staffing, and financial resources are available to support it.

The hospital collects information regarding each physician's or other licensed practitioner’s...

The hospital must collect and verify credentialing information for practitioners seeking privileges and, for deemed status hospitals, ensure qualified radiologist supervision of ionizing radiology services.

The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an o...

The standard requires objective, evidence-based criteria and procedures for granting, renewing, and documenting clinical privileges, including surgical and obstetrical privileges where applicable.

The organized medical staff reviews and analyzes all relevant information regarding each requ...

The standard requires the organized medical staff to review relevant practitioner qualifications and complete privileging decisions using health care quality-related criteria without specified discriminatory factors.

An expedited governing body approval process may be used for initial appointment and reappoin...

The standard permits expedited governing body approval for medical staff appointment, reappointment, and privileges when defined eligibility criteria are met.

Under certain circumstances, temporary clinical privileges may be granted for a limited perio...

The standard sets conditions, verification steps, approval roles, and duration limits for granting temporary clinical privileges.

Deliberations by the medical staff in developing recommendations for appointment to or termin...

Medical staff deliberations for appointment, termination, and clinical privilege decisions include peer recommendations addressing competence and professional attributes.

The organized medical staff defines the circumstances requiring monitoring and evaluation of...

The organized medical staff defines and implements criteria, triggers, monitoring plans, and resolution measures for evaluating practitioner performance.

Ongoing professional practice evaluation information is factored into the decision to maintai...

Ongoing professional practice evaluation information is used to determine whether existing clinical privileges should be continued, limited, revised, or revoked.

The organized medical staff, pursuant to the medical staff bylaws, evaluates and acts on repo...

The hospital and organized medical staff maintain a defined process for collecting, investigating, and addressing concerns about privileged practitioners’ clinical practice or competence.

There are mechanisms for a fair hearing and appeal process to address adverse decisions regar...

The organized medical staff must have a fair hearing and appeal process for adverse privilege and reappointment decisions related to quality of care issues.

The medical staff develops and implements a process to identify and manage matters of individ...

The medical staff must implement a confidential process to identify, refer, monitor, and respond to physician or practitioner health and impairment concerns separately from discipline.

All physicians and other licensed practitioners privileged through the medical staff process...

Privileged physicians and other licensed practitioners must participate in continuing education that is documented and considered in reappointment and privileging decisions.

Physicians or other licensed practitioners who are responsible for the care, treatment, and s...

The originating hospital must credential and privilege telemedicine practitioners or include specified safeguards when relying on distant-site credentialing and privileging decisions.

For originating and distant sites:

Medical staffs at originating and distant sites recommend which clinical services are appropriately delivered through a telemedicine link and ensure offered services align with accepted quality standards.

The hospital has a process in place to correctly identify patients when providing care, treat...

The hospital uses processes such as two patient identifiers, specimen container labeling in the patient’s presence, and distinct newborn identification methods to correctly identify patients.

The hospital reports critical results of tests and diagnostic procedures on a timely basis.

The hospital maintains written procedures for defining, reporting, timing, and evaluating critical results of tests and diagnostic procedures.

The hospital manages the flow of patients throughout the hospital.

The hospital measures, sets goals, reviews results, and takes leadership action to manage patient flow, bed availability, throughput, support services, and emergency department boarding.

The hospital has a process for handoff communication.

The hospital has a process for sharing patient information during internal handoffs, including an opportunity for discussion between sender and receiver.

The hospital improves the safety of clinical alarm systems.

The hospital identifies important alarm signals and establishes policies for alarm settings, authority, monitoring, response, and signal checks.

The hospital recognizes and responds to changes in a patient’s condition.

The hospital develops and implements written criteria for early warning signs of patient deterioration and appropriate actions to take.

Resuscitative services are available throughout the hospital.

The hospital provides resuscitative services under standards and policies, makes equipment available for the population served, and trains involved staff.

The hospital develops and implements processes for post-resuscitation care.

The standard addresses hospital policies, procedures, or protocols for interdisciplinary post–cardiac arrest care and neurological prognostication.

The hospital reviews resuscitation cases to identify opportunities for improvement.

The standard addresses interdisciplinary review of resuscitation cases and data to identify practice and system improvement opportunities.

The hospital conducts a preprocedure verification process.

The standard addresses verification of the correct patient, procedure, and site and availability of required procedure-related items before a procedure.

The hospital marks the procedure site.

The standard addresses when and how procedure sites are marked, who may mark them, and alternative processes when marking is refused or impractical.

The hospital performs a time-out before the procedure.

The standard requires a standardized team time-out immediately before invasive procedures or incisions and documentation of its completion.

The mission, vision, and goals guide the hospital’s actions.

The standard requires hospital governing, senior, and medical staff leaders to create and communicate mission, vision, and goals that guide leadership actions.

The hospital addresses conflicts of interest and ethics.

The standard requires hospital leaders to define, disclose, and manage conflicts of interest and to provide a process for staff, patients, and families to address ethical issues.

The hospital’s leaders design work processes to focus individuals on safety and quality issues.

The standard requires hospital leaders to implement patient safety program structures, reporting systems, event analyses, risk assessments, communication processes, safety culture evaluation, and conduct management.

The hospital has a workplace violence prevention program.

The hospital must implement a multidisciplinary workplace violence prevention program that includes policies, incident reporting, victim support, staff training, and annual worksite analysis.

Hospital leaders provide oversight and support of the emergency management program.

Hospital leadership must provide oversight and support for the emergency management program, including the appointment of a qualified lead and the establishment of a multidisciplinary committee.

The hospital develops an emergency operations plan based on an all-hazards approach.

The hospital must maintain an all-hazards emergency operations plan that includes a scalable incident command structure and designated authority for activation.

The hospital has a communications plan that addresses how it will initiate and maintain commu...

The hospital must implement a communications plan to maintain contact with staff, patients, and community partners during emergency or disaster events.