Polytechnic University of Puerto Rico

BME 4030: Clinical Engineering Course

Prof. Jonathan Marrero-Rosaly
Frances Díaz De Jesús
Student Number: 77248
Homework 2
Paper: The Joint Commission
The aim of this paper is to define The Joint Commission organization, specify the importance in Clinical Engineering
and mention what regulations hospitals need to fallow to get accredited by the Joint Commission.
Throughout research in the Joint Commission (JC) website I can now clearly mention that it is the nation’s oldest and
largest standards-setting and accrediting body in health care. It is an independent organization that accredits and
certifies around 22,000 health care organizations and programs in the United States. As such, the Joint Commission
currently accredits over 80% of U.S. hospitals. It is also important to mention that JC accreditation and certification is
an organization recognized nationwide as a symbol of quality that reflects their commitment to meeting certain
performance standards. In the website the organization specifies that their mission is to continuously improve health
care for the public by evaluating health care organizations and inspiring them to excel in providing safe and effective
care of the highest quality and value.
Getting certified is earned by programs or services that are based within or associated with a health care organization.
For example, a Joint Commission accredited health care center can also have Joint Commission certified programs or
services within a medical specialty. What I am trying to clarify is that these programs could be within the health care
center or in the community. Any clinical program using evidence-based, sponsored clinical practice guidelines can be
considered for Joint Commission International (JCI) certification. On the other hand, The Joint Commission
accreditation can be earned by various types of health care organizations, including hospitals, doctor’s offices, nursing
homes, office-based surgery centers, health treatment facilities, and providers of home care services. Internationally
speaking, JCI accreditation is considered as the gold standard in global health care and JCI consultants are constantly
addressed as the most skilled and experienced in the industry.
Below are listed different types of health care settings or health conditions that can be accredited or certified by The
Joint Commission. Hence, the lists are exactly the same as found on the Joint Commission website.
• Health care settings that can be accredited by The Joint Commission:
1. Hospital: General, pediatric, psychiatric, rehabilitation and critical access hospitals
2. Ambulatory care: Clinics, dental and medical practices, dialysis centers, imaging centers, urgent care
centers, office-based surgery practices
3. Nursing care center: Nursing homes, rehabilitation centers
4. Behavioral health care: Mental health services, addiction treatment services, and human services for
children, youth and families
5. Home care: Medical equipment, pharmacy, hospice services
6. Laboratory services: Independent or freestanding clinical laboratories
• Health conditions that can be certified by The Joint Commission:
1. Disease-Specific Care Certification: Cardiovascular, hematology/oncology, neonatal/perinatal, neurological,
orthopedic, pediatric, women's health
2. Advanced Certification: Chronic kidney disease, comprehensive cardiac and stroke centers, heart failure,
palliative care, primary stroke centers, thrombectomy-capable stroke center, total hip and total knee
replacement
3. Other certifications: Health care staffing services, integrated care, medication compounding, memory care,
primary care medical home
In my opinion, since in today’s society the volume and complexity of biomedical equipment and medical devices in
hospitals have been significantly growing it has also been creating legal implications for clinical engineers. Decisions
on product liability, statutory regulations, and the patient's right to privacy and confidentiality are some of the many
reasons that affect daily operations. Meaning that the need for clinical engineers to be alert to their legal obligation is
being assessed. Therefore, since clinical engineers and the healthcare technology management staff works with the
selection, acquisition, implementation, and installation of modern medical equipment systems the role of the Joint
Commission increases. At the same time the concern over the management of medical technology in hospitals is also
growing which it has caused the Joint Commission to make changes pertaining to medical technology for the
accreditation of hospitals. The importance for a hospital having a Joint Commission accreditation is due to the fact
that it is a widely recognized standard in terms of evaluation and demonstration of excellent quality services, thus it
ensures that the hospital provides high quality, efficiency and effective services. The accreditation is also important
because it represents the Gold Seal of Approval in health care and provides the most comprehensive evaluation
process in the industry.
The Joint Commission accreditation process seeks to help identify known or unknown risks to quality and patient
safety, and aims to inspire organizations to improve their care, treatment and services. The standards are the basis of
an evaluation process that helps health care organizations measure, assess and improve their performance. In general,
they focus on important patient, individual, or resident care and functions that are essential in providing safety and
high-quality care. They set expectations for organization performance that are reasonable, achievable and surveyable.
Joint Commission standards are developed with input from health care professionals, providers, subject matter
experts, consumers and government agencies. The place to begin, when preparing for accreditation, is the Joint
Commission’s Comprehensive Accreditation Manual for Hospitals (CAMH). It contains functional standards that are
organized around how care is provided. They address critical patient safety and overall quality issues and are presented
as patient-focused or organization-focused functions and processes. The specific standards that a hospital needs to
fallow in order to get accredited by Joint Commission are not available on the website, but I was able to find the
standards development process. In general, they include the following steps:
• Emerging quality and safety issues suggesting the need for additional or modified requirements are identified
through the scientific literature or discussions with The Joint Commission’s standing committees and advisory
groups, accredited organizations, professional associations, consumer groups or others.
• The Joint Commission prepares draft standards using input from technical advisory panels, focus groups, experts
and other stakeholders.
• The draft standards are distributed nationally for review and made available for comment on the Standards Field
Review page of The Joint Commission website.
• After any necessary revisions, standards are reviewed and approved by executive leadership.
• The survey process is enhanced, as needed, to address the new standards requirements, and pilot testing of the
survey process is conducted.
• Surveyors are educated about how to assess compliance with the new standards.
• The approved standards are published for use by the field.
• Once a standard is in effect, ongoing feedback is sought for the purpose of continuous improvement.

Also, JC established its National Patient Safety Goals (NPSGs) in 2002 with the purpose to improve the safety of patients
by helping accredited organizations address the specific areas of concern in regard to health care safety and to focus
on how to solve them. The NPSGs are one of the major methods by which The Joint Commission establishes standards
for ensuring patient safety in all health care settings. In order to ensure that health care facilities focus on preventing
major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and
effectiveness.
On the other hand, surveys, conducted every three years, are made unannounced and are designed to be
individualized to each organization, to be consistent, and to support the organization’s efforts to improve
performance. They evaluate an organization’s performance of functions and processes aimed at continuously
improving patient outcomes. The purpose is to assess the extent of an organization’s compliance with applicable Joint
Commission standards, NPSGs, and Accreditation Participation Requirements. Another important aspect of the survey
process is the on-site education as surveyors offer suggestions for approaches and strategies that may help the
organization better meet the intent of the standards and improve performance. The accreditation decision process is
made based on the scoring obtained on an evaluation of compliance with Joint Commission standards and other
requirements.
A preliminary denial of accreditation results when there is justification to deny accreditation to a health care
organization based on the number of not compliant standards exceeds established thresholds at the time of survey.
The decision is subject to appeal prior to the determination to deny accreditation; the appeal process may also result
in a decision other than denial of accreditation. An organization is denied accreditation if it did not permit a survey, or
if it failed to meet the requirements for timely data submission, resolve a Conditional Accreditation status, or submit
required fees.
In conclusion, I would say that the proper role of the Joint Commission accreditation for a hospital, in terms of this
paper, involves principles associated with clinical engineering, and the proper management of medical technology
based on quality to demonstrate excellence. Meaning that more approaches by clinical engineers may help to advance
the cause of a better health care.
References:
1. About Our Standards Joint Commission. (n.d.). Retrieved from
https://www.jointcommission.org/standards_information/standards.aspx
2. Accreditation Guide for Hospitals Joint Commission. (2017, December 5). Retrieved from
https://www.jointcommission.org/accreditation_guide_for_hospitals/
3. How To Become Accredited Joint Commission? (n.d.). Retrieved from
https://www.jointcommission.org/accreditation/hospital_seeking_accreditation.aspx
4. National Patient Safety Goals® Joint Commission. (n.d.). Retrieved from
https://www.jointcommission.org/standards_information/npsgs.aspx
5. https://www.jointcommission.org/assets/1/18/171110_Accreditation_Guide_Hospitals_FINAL.pdf
6. https://www.jointcommission.org/assets/1/18/Inspiring_Health_care_excellnce_brochure_8-101.PDF
7. https://accenet.org/publications/Downloads/Reference%20Materials/ACCEPatientSafetyWhitePaper.pdf