The following chart shows the differences between accreditation and licensure/certification:

Accreditation Surveys State Surveys

Purpose Performance improvement; deemed status in some states licensure and/or Medicare/Medicaid provider certification

Oversight private, not-for profit company governmental entity

Compliance voluntary mandatory

Emphasis evaluation inspection

Frequency triennial annual

Funding provider fees tax dollars

Focus What is the organization doing right? How can it improve? What is the organization doing wrong?

Expectations achievable standards minimum expectations

Scoring systems and processes individual deficiencies

Value improvement enforcement

Process survey to standards survey to regulations

Approach education/consultation sanctions/penalties/fines

Findings recommendations for improvement citations

Award accreditation licensure or certification How to Become Accredited? Eligibility for Hospital and Critical Access Hospital Accreditation In order for an organization to be accredited under Hospital program, the following requirements determine eligibility.

� The organization is located in the United States or its territories or, if outside the United States, is operated by the U.S. government, or under a charter of the U.S. Congress.

� The organization assesses and improves the quality of its services. This process includes a review of care by clinicians, when appropriate.

� The organization identifies the services it provides, indicating which services it provides directly, under contract, or through some other arrangement.

� The organization provides services addressed by the Joint Commission's standards. � In order for an organization to be accredited under our Critical Access Hospital program, the following requirements

determine eligibility. The critical access hospital must be located in the United States or its territories or, if outside the United States, is operated by the U.S. government, or under a charter of the U.S. Congress, meeting the following criteria:

� The nature of the health care practices in the applicant critical access hospital is compatible with the Joint Commission standards and their elements of performance.

� With the use of interpreters provided by the critical access hospital, as necessary, the surveyors can effectively communicate with substantially all of the critical access hospital's management and clinical personnel and at least half of the critical access hospital's patients, and can understand medical records and documents that relate to the critical access hospital's performance.

� United States citizens make up at least 10% of the critical access hospital's patient population, or a United States government agency contracts with the critical access hospital to provide services to United States citizens, or United States citizens preferentially use the critical access hospital in that country.

� The critical access hospital assesses and improves the quality of its services. This process includes a review of care by clinicians, when appropriate.

� The critical access hospital identifies the services it provides, indicating which services it provides directly, under contract, or through some other arrangement.

� The critical access hospital provides services addressed by the Joint Commission's standards. Accreditation Process Preparing for a Hospital Survey Preparing for a Joint Commission survey can be challenging. The hospital must:

� Know the standards; � Examine the current processes; � Improve areas that are not currently in compliance; and � Must be in compliance with the standards for at least four months prior to your initial survey. For resurveys, it requires a

12-month "track record" of standards implementation. However, it expects the hospital to be in compliance with applicable standards during the entire period of accreditation, so surveyors will look for a full three years of implementation for several standards-related issues, including performance improvement activities.

For an initial survey, allow 9-12 months of preparation before the survey date. The management will have sufficient time to:

� Review the standards carefully; � Conduct an organizational self-assessment; � Take measures to improve where needed; � Develop new policies or processes; and � Conduct staff training

The following checklist can help you prepare for an initial or triennial survey.

� Read all the information in the Comprehensive Accreditation Manual for Hospitals (CAMH). This manual includes all the hospital standards as well as a section covering official Joint Commission accreditation policies and procedures. Read all the standards and determine their relevance to your hospital. Remember that you are responsible for items in the intent statements as well as in the standards; be sure to read the scoring guidelines. Surveyors will look for multidisciplinary or organization wide approaches to the standards, so don't limit your compliance to specific departments or disciplines. The examples of implementation and the scoring guidelines can help you understand the meaning of the standards and intent statements.

� Attend seminars to help you understand the standards. Besides the many seminars that we sponsor throughout the year, state hospital associations and other professional associations often give presentations on Joint Commission standards. Read some of the many publications and other resources on hospital standards and related topics. For answers to questions about a specific standard, call the Department of Standards at 630-792-5900.

� Network with colleagues from hospitals that have recently gone through the accreditation process. Attend professional association meetings or call your counterparts in other organizations. Online bulletin boards sponsored by professional associations can be particularly helpful.

� Ensure that staff understand how to comply with the standards. Develop programs to educate staff about new systems. The surveyors will interview staff members to see how well they understand your processes.

� Use the scoring guidelines in the CAMH to conduct a mock survey. Document any areas of partial compliance and noncompliance that you identify. Mock surveys are most helpful when conducted regularly throughout the accreditation cycle. Regular mock surveys help you judge your hospital's efforts at continuously improving performance and help you fix problems before surveyors arrive. Some organizations hire consultants to conduct mock surveys if they don't have the time or expertise to do it themselves.

� Review the results of your mock survey with your staff. Develop a plan to correct the problems you found and set priorities for improvement. Establish a realistic schedule for improvements. We offer several tools to assist you. Visit the Joint Commission Resources website for more information.

� Immediately before your survey, meet with your staff to review expectations and relieve anxiety. Reviewing what will happen during the survey will help boost staff confidence and help your people relax.

The best way to prepare for a survey is to incorporate the standards requirements into your daily activities. By continuously improving your hospital's processes, you can improve existing methods and correct problems before they become serious.

Comprehensive Accreditation Manual for Hospitals (CAMH) Status Definitions Ethics, Rights and Responsibilities Individual Rights

� Filming And Recording � Organ Donation � Patient Rights and Informed Consent When Videotaping or Filming

Provision of Care Assessment

� Nutritional, Functional, And Pain Assessments And Screens � Pre-Induction Assessment For Sedation And Anesthesia � Updates to the Patient's Condition � History And Physical For Hospital Outpatient Procedures � H&P from Non-Credentialed Practitioners � History and Physical for Surgery � Spiritual Assessment � Authentication of H&P in 24 hours � LPNs Performing Assessment

� Breathalyzers, Continuous Glucose Monitoring Systems, Pulse Oximeters & Transcutaneous Bilirubinometers � H&P Older Than 30 Days/Using the Prenatal Record � Dictated History and Physical � Content of the History and Physical

Waived Testing

� Patient/Client Self Glucose Testing � Physician Competency For Waived & P.P.M.P. Testing � Survey Of Urine Drug Testing In A Behavioral Health Care Facility � Waived Testing Logs � Screening Vs. Definitive � Reference Ranges In Medical/Clinical Record � Reagents Stored With Medications Or Specimens � Professional Vs. Home Use Tests (Glucose Meters, Etc.) � Provider Performed Microscopy Procedures (P.P.M.P.) � Color-Blind Testing

Operative/High-Risk Procedures/Sedation/Anesthesia

� Follow-up Phone Calls In Outpatient Surgery � Procedures Requiring Surgical Site Marking � Sedation and Anesthesia � Moderate Sedation Medication and Patient Monitoring � Permission to Administer Moderate Sedation

Behavioral Health Care Restraint and Seclusion

� Residents or House Staff Writing Orders and/or Evaluating a Patient for Restraint or Seclusion for Behavioral Health Reasons;

� Special Interventions (Behavioral Health Restraints & Seclusion); � Restraint and Seclusion.

Tissue Storage or Issuance

� Applicability of the Tissue Storage & Issuance Standards � Autologous Bone Flaps � Responsibility & Oversight � Tissue Source Facilities - Verification of Licensing & Registration � Temperature Recording, Monitoring, Alarms and Back-Up Storage � Verifying the Package upon Receipt � Tissue Redistribution to another Healthcare Facility � Traceability of Records � Adverse Tissue Reaction Policies

Medication Management Patient-Specific Information

� Minimum Patient Information - Medication Selection and Procurement

� Strength And Dosage Form Listing

� Monitoring Patient Response � Medication Refrigerator Temperature Logs � Annual Review of Formulary or Drug List � Define "Concentrated Kcl"

Ordering and Transcribing

� Diagnosis, Condition, Indication-For-Use In Order � Reordering Medications At Transfer

Preparing and Dispensing

� Pharmacy Review For Licensed Independent Practitioner Controlled Medication � Labeling Medication For Anesthesia

Surveillance, Prevention and Control of Infection The IC Program and Its Components

� Licensed Independent Practitioner Health Screening � Infection Control Applicability To Offsite Interpretive Reading Providers � Food And Drinks In Patient Care Areas

Leadership Leadership

� Credentialing And Privileging For Providers From Joint Commission Accredited Organization � Annual Requirements in New Standards

Management of Environment of Care Planning and Implementation Activities

� Security of Syringes and Needles � Temporary Construction Barriers � Eyewashes - Frequency of Flushing � Trash Cans � Blood Warmers - Alarm Check Documentation � Infant Abduction Drills � Utility System and Acquired Illness � Undersink Storage � Tabletop Drills � Standpipe Fire Hose Testing � Staff Only Refrigerators � "Paper Patient" Drills � One-Time Extension Based on Unforeseen Conditions � Management Plans in Business Occupancies � Hazardous Material � Exit Maps � Emergency Management � EC Management Plans in Several Settings � Disaster Drills

Management of Human Resources Planning

� Staffing Effectiveness � Human Resource Standards Applicability to Contracted and Volunteer Personnel � Primary Source Verification � Requirements for Criminal Background Checks

Management of Information Confidentiality and Security

� Medical Records Security After Hours Information Management Processes

� Laboratory Report Requirements In The Medical Record � Acceptable Abbreviation List

Patient Specific Information

� One LIP Signing for Another � Summary Lists - Divergent Components � Operative Reports � Authentication Using A Single Document � Ambulatory Summary List � Authentication of the H&P in 24 Hours � Authentication of Documentation � Medical Staff

Continuing Education

� Documenting CME's Credentialing and Privileging and Appointment

� Ongoing Professional Practice Evaluation (OPPE) � Primary Source Verification of Education for Licensed Independent Practioners � Core/Bundled Privileges � Reappointment/Reprivileging Dates � Expediting the MEC Function � Organ Procurement Team Privileging � Credentialing Non-Medical Staff Member Licensed Independent Practitioners Who Order tests and Treatments from a

Joint Commission Accredited Organization � Provision of a Fair Hearing � Credentialing and Privileging in Hospital-Based* Long Term Care surveyed under the Comprehensive Accreditation

Manual for Long Term Care � Credentialing and Privileging in Hospital-Based* Behavioral Health Care settings surveyed under the Comprehensive

Accreditation Manual for Behavioral Health Care � Verifying Work Experience � Verification of Credentials Information � Permission to Administer Moderate Sedation � Peer References

Management of Patient Care, Treatment and Services

� Medical Students Doing H&P � Podiatrist and Dentist Performing the Entire History and Physical for Inpatient and Outpatient Care � Delegation of the History and Physical Examination

Other Frequently Asked Questions: How do I find out how other health care organizations rate with the Joint Commission? - With JCI online Quality Check™, you can "check up" on the performance of health care facilities, by reviewing their latest

Quality Report. How do I register a complaint about a health care organization? - You can complete our online Quality Incident Report Form. For more information, please call 800-994-6610. Who can answer a question about standards interpretation? - Please check the Standards FAQs section of JCI website. If you don't find your answer there, you can complete the Online

Standards Form or call 630-792-5900. How soon after I apply can I be surveyed? - Your organization can normally be surveyed within three to four months after we receive your application. However, the key

issue is whether you are ready to be surveyed. We will evaluate the past four months of service for compliance with the standards. If your organization is beginning to prepare for survey at the time of application, it should request to be surveyed at least four to six months later. Your application for survey is valid for 12 months from the date it is submitted. You may request a specific month for your survey and we will try to accommodate you.

How long does it take to prepare for survey after I receive the manual? - This varies considerably from organization to organization and depends on the amount of time and resources available to

prepare for survey. Most organizations take one full year from the point of the initial decision to the actual survey date. How long must we be in compliance with the standards before survey? - You must be in compliance for four months on an initial survey, twelve months on a resurvey. We don't expect a track record

of compliance for a preliminary accreditation survey (early survey option one). When will we get our report? When can we start advertising our accreditation? - This varies with the number of surveys conducted in the previous month but averages about 15 days. Your organization is

retroactively accredited to the day after survey, but you may not market your accreditation until you receive the final award letter.

What happens to my accreditation when I sell my organization or am acquired by another organization? If I add a new service, is it automatically accredited until the time of my next survey? - We do not automatically transfer accreditation to new owners who acquire an accredited health care organization.

Accreditation will not continue if significant changes occur to the circumstances existing at the time of the previous survey. An accredited organization must notify us no more than 30 days after it merges, is acquired, or undergoes any major change in services, location, capacity, or corporate structure. We will extend accreditation until we can determine if a special survey is necessary. Failure to notify us of ownership and service changes can result in a loss of accreditation.

Where can I buy a survey manual? - Contact the Customer Service Center toll free at 877-223-6866. You can view a catalog of all our publications online at

www.jcrinc.com. How do I determine if my group of hospitals can use the multi-hospital survey option, or if we must be surveyed as a network? - If your system owns or operates at least two hospitals, you may be able to use the multi-hospital survey option. However, if

your hospitals do not each have their own medical staffs and unique patient populations, we may survey you under health care network standards. A hospital network offers a continuum of care and will refer patients to the most appropriate facility. If several of your hospitals draw from the same geographic population (sending cardiac cases to one hospital, pediatrics to another, for example), you may be a network.

Our hospital owns a physician group. Will the physician practice be included in our hospital survey? - We survey physician groups as part of the hospital if they are organizationally and functionally integrated with the hospital, or if

the hospital publicly represents the group as part of its organization. What is continuous accreditation? Why should my hospital be interested in it? - The Joint Commission surveys most hospitals every three years. In the final 12 months of this cycle, a hospital may spend

considerable time, effort, and money to get ready for the survey. The hospital looks closely at its performance improvement

efforts and measures the results to find out if they meet survey requirements. Once the survey is over, the hospital may return to "business as usual" and may reduce its focus on performance improvement.

- Hospitals that participate in continuous accreditation efforts monitor and improve their performance every day, not just in preparation for a survey. At any point in the accreditation cycle, these hospitals know if their performance efforts are working. Continuous improvement efforts help hospitals maintain the highest quality of patient care and services. In addition, hospitals can use their resources more wisely, avoiding the high cost of gearing up for a Joint Commission survey.

Can a surgical hospital or a long term acute care hospital be accredited by the Joint Commission? - Yes, they would be accredited using the hospital accreditation manual. I am a surgical hospital, am I required to have an emergency department, intensive care unit, pharmacy, radiology, and a laboratory? - No, your organization is not required to have these essential services if you are a surgical hospital. If your organization

provides these services via a contract, then only the contract would be evaluated at the time of survey. I am a long term acute care hospital, am I required to have an emergency department, intensive care unit, pharmacy, radiology, and a laboratory? - No, your organization is not required to have these essential services if you are a long term acute care hospital. If your

organization provides these services via a contract, then only the contract would be evaluated at the time of survey. Example of Comprehensive Accreditation Manual for Hospital: The Official Handbook (CAMH)