What is the Joint Commission?

Bryan Knowles
3 days ago
5 min read

This is part one of a series exploring the various organizations that perform inspections. So, first we'll be exploring what the Joint Commission does, why it exists, and how you can be better prepared for an inspection.

So, Let's Start at the Beginning: What Is the Joint Commission?

This is the organization that most people who have worked in a hospital will already be familiar with, or at least have heard the name (often referred to as "J Co"). This is because they inspect all parts of the hospital including nursing. But they also inspect the laboratory, as we'll see.

The Joint Commission is an independent, nonprofit organization that accredits and certifies health care organizations and programs in the United States. Founded in 1951 through the consolidation of several professional standards organizations, it has evolved into the most influential accrediting body for hospitals and many other health care settings, including ambulatory care centers, laboratories, behavioral health facilities, and home health agencies. Its primary mission is to continuously improve health care quality and patient safety by establishing evidence-based standards, evaluating organizational performance against those standards, and promoting best practices across the continuum of care.

For medical professionals, the Joint Commission is most visible through its accreditation surveys, its National Patient Safety Goals, and its extensive standards manuals. These standards address governance, leadership, infection prevention, medication management, environment of care, and clinical processes, among many other domains. Accreditation by the Joint Commission is widely regarded as a marker of institutional credibility and commitment to quality improvement rather than a mere regulatory obligation.

How Does It Relate to CMS?

The relationship between the Joint Commission and Centers for Medicare & Medicaid Services is central to understanding its practical importance. CMS is the federal agency responsible for administering Medicare, Medicaid, and other federal health programs, and it establishes Conditions of Participation that hospitals must meet in order to receive reimbursement. Rather than conducting routine inspections of every hospital itself, CMS grants certain accrediting organizations “deeming authority,” meaning that accreditation by those organizations is accepted as evidence of compliance with CMS requirements.

The Joint Commission is the most prominent organization with deeming authority. When a hospital is accredited by the Joint Commission, CMS generally considers it to be in compliance with Medicare and Medicaid Conditions of Participation, without requiring a separate CMS survey. While CMS retains the right to conduct validation or complaint-driven surveys, Joint Commission accreditation effectively serves as a proxy for CMS regulatory compliance, making it financially critical for hospitals.

What Does a Failure of a Joint Commission Inspection Mean for a Hospital?

Failure during a Joint Commission survey can have serious operational, financial, and reputational consequences. Deficiencies are categorized based on their severity, with the most serious findings labeled as "Immediate Threat to Life" or findings that result in a decision of denial, conditional accreditation, or preliminary denial of accreditation. Such outcomes indicate systemic failures in patient safety or quality systems rather than isolated lapses. From a practical standpoint, significant deficiencies require rapid corrective action plans, intensive follow-up, and, in some cases, resurveying. If accreditation is ultimately lost, CMS deeming status may also be jeopardized, placing Medicare and Medicaid reimbursement at risk. Beyond regulatory and financial implications, failed surveys can erode staff morale, damage public trust, and expose the organization to increased legal and malpractice risk. For clinicians and laboratory professionals alike, these failures often translate into increased scrutiny of documentation, workflows, and competency validation.

At the very least, failures during inspections, even small ones, can cause large headaches for organizations as they need to change processes to fix issues as prevent issues from occurring in the future.

How to Prepare for an Inspection

First off, don't panic. Second, if you're disorganized, start panicking.

The key to performing well on an inspection is to be prepared and organized well in advance. And the best way to be organized is to use checklists. Luckily, the Joint Commission, like many other accreditation organizations produce checklist to help hospitals prepare for inspections. HERE is one to get you started for the Joint Commission. Appropriately t's called the BIG BOOK OF CHECKLISTS.

How to Get Staff Ready

A huuuuuge part of being ready for an inspection is to prepare and train your staff well. If your staff is poorly trained, you are bound to get docked on an inspection. Go over previous failures with them and let them get involved with self-inspections. This is the way to demonstrate the gravity of errors in documentation and

What are Some of the most common Joint Commission failures?

Infection Prevention and Control Lapses: Infection control failures remain a high-frequency citation area, particularly since heightened regulatory scrutiny following the COVID-19 pandemic. Common problems include inconsistent hand hygiene practices, improper use or storage of personal protective equipment, lapses in cleaning and disinfection of equipment, and failure to follow isolation protocols. Surveyors often observe real-time practice rather than relying solely on policies, making gaps between written procedures and actual behavior especially vulnerable to citation.

Medication Management Errors: Medication management deficiencies are another frequent source of findings. These include improper labeling of medications and syringes, unsecured medication storage, look-alike/sound-alike drug risks, expired medications on patient care units, and incomplete medication reconciliation. The Joint Commission places particular emphasis on high-alert medications and transitions of care, where breakdowns in process can lead to serious patient harm.

Documentation and Policy Noncompliance: A significant number of inspection failures arise from documentation gaps rather than absence of clinical activity. Examples include missing or outdated policies, incomplete competency assessments, inconsistent staff training records, and lack of evidence that required audits or reviews were performed. Even when processes are occurring in practice, failure to document them in a manner that meets accreditation standards can result in citations. Surveyors expect documentation to demonstrate sustained compliance, not just point-in-time correction.

Failure to Consistently Follow Hospital Policies and Procedures: Perhaps the most preventable category involves staff not following the organization’s own approved policies. These findings often emerge during tracer activities when surveyors follow a patient’s care pathway and observe deviations from established protocols. Examples include failure to perform required patient identification steps, incomplete time-outs before procedures, or inconsistent use of safety checklists. The Joint Commission views such failures as indicators of system-level reliability problems rather than isolated staff errors.

Life Safety Code and Environment of Care Deficiencies: The most common failures involve noncompliance with Life Safety Code and Environment of Care standards. These findings typically relate to fire safety, building infrastructure, and physical plant maintenance rather than direct patient care. Frequently cited issues include blocked or improperly maintained fire doors, missing or outdated fire drills, improper storage of oxygen cylinders, unsecured hazardous materials, and incomplete documentation of routine safety inspections. While these deficiencies may appear administrative, they are treated seriously because they directly affect patient and staff safety during emergencies.

What to do During and Inspection: Tips for Success

Provide a clean space: When the inspectors show up, the best thing you can do is prepare a dedicated, clean space for them to review documentation. Give them a conference room. This prevents them from accidentally finding things that are sitting around that may bring something to their attention. When they see something,
Have staff refer to a supervisor for any inspection questions. Don't allow things to go off course with possibly inexperienced workers answering questions incorrectly or leading inspectors to a trouble spot.
Be forthcoming with documentation. If you can provide all documentation, it leaves no room for digging through files.
Be courteous. This is very important. If an inspector brings up a topic regarding a possible infraction, be helpful, not argumentative. Sometimes inspectors will allow you to fix something at that time if you are helpful and contrite. Don't be an A**hole.