Joint Commission

The Joint Commission is the largest health care accreditor in the United States, surveying hospitals, critical access hospitals, ambulatory care, behavioral health, home care, laboratories, nursing care centers, and office-based surgery practices.

For hospitals and several other settings it holds CMS deeming authority, so its accreditation stands in for the state agency Medicare certification survey.

Its standards manuals organize requirements into chapters such as leadership, environment of care, emergency management, infection prevention and control, medication management, provision of care, human resources, and the National Patient Safety Goals.

Many standards carry written requirements: policies for restraint and seclusion, medication management, infection prevention, emergency management plans and hazard vulnerability analysis, environment of care management plans, credentialing and privileging processes, patient rights documents, and performance improvement plans.

Surveyors use tracer methodology, following individual patients and systems through the organization, so they look for the policy and then for the record that shows staff followed it.