1. Created by Jennifer Discher, Mallory Gilbert, Shari Hendrickson, & Derrek Staley
NURS 320
Fall 2013

2. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Once attaining accreditation from The Joint Commission, an organization can display the seal on their publications, informing the public of their achievements in high standards of care.

3. JCAHO
“A private nongovernmental agency that establishes guidelines for the operation of hospitals and other health care facilities, conducts accreditation programs and surveys, and encourages the attainment of high standards of institutional medical care in the United States. Members of the JCAHO include representatives from the American Medical Association, American College of Physicians, American College of Surgeons, American Dental Association, and American Hospital Association” (Mosby’s, 2009).

4. Joint Commission Mission/Vision Statement
Mission: “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Joint Commission, 2009). Vision: “All people always experience the safest, highest quality, best-value healthcare across all settings” (Joint Commission, 2009).
Joint Commission. (2009). The mission statement. Retrieved from

5. Who created JCAHO?
Dr. Ernest Codman is credited as being a founder of JCAHO. Dr. William Mallon describes Dr. Codman as “a graduate of Harvard Medical School and one of the founders of the American College of Surgeons. Also forming the Committee for Hospital Standardization” (Mallon, 2013).

6. Who created JCAHO?
Dr. Codman’s goal was to ensure quality and safety of patient care.
Dr. Codman wrote “We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians” (Mallon, 2013).
These ideas would become the foundation used to form the Committee for Hospital Standardization.

7. Who created JCAHO?
The Committee for Hospital Standardization began as an attempt to study hospital outcomes (end results) and see how they could be improved (Mallon, 2013).
The committee still exists today, but over the passage of years has transmogrified into the Joint Commission for Accreditation of Hospital Organizations (Mallon, 2013).

8. Why was JCAHO created?
JCAHO was created to standardize all patient care, in doing so the hope was to ensure quality and safety of patient care. If standards were not being met then the goal was to improve the current quality of care. (The Joint Commission, 2013).
JCAHO was created to standardize care throughout the health care system. The goal was to provide a way to ensure quality and safety of patient care. If the standards were not being met then the goal was to provide a way to improve patient care (Joint Commission, 2013e).

9. History of The Joint Commission
“The Joint Commission is the nations oldest and largest standards-setting and accrediting body in health care” (Joint Commission, 2013e). The agency, formed from what was originally called The American College of Surgeons (ACS),
est. 1913, was formed using the vision of surgeon Ernest Amory Codman MD, who in 1910 devised a system that could assess the effectiveness of treatment of hospitalized patients in order to standardize hospital care (Joint Commission, 2013f). This lead to voluntary inspections of hospitals in 1918 (AHLA, 2013), in which only 89 of 692 hospitals met the minimum standards (Joint Commission, 2013f). T

10. History of The Joint Commission cont.
By 1951 the ACS joined forces with American College of Physicians, American Hospital Association, and the Canadian Medical Association forming the Joint Commission on Accreditation of Hospitals (JCAH), whose purpose was to provide accreditation to hospitals attaining the minimal standards set by the agency (AHLA, 2013). In 1970 the focus of the agency changed from minimal standards to attaining the most optimal standards. In 2007, JCAHO shortened their name to Joint Commission and in 2012 accredited the 20,000th organization that met their standards (Joint Commission, 2013f).

11. Courtesy of Google Images
The Joint Commission
(Joint Commission, 2013f)
1910 Ernest Amory Codman MD proposes a system to assess the effectiveness of healthcare treatments in hospitalized patients in order to standardize healthcare in hospitals.
1913 The American College of Surgeons (ACS) is formed using the standards identified by Codman.
1917 The ACS develops a full one page of hospital healthcare standards called “The Minimum Standards for Hospitals”.
1918 The ACS inspects 692 hospitals and discover only 89 meet the minimum standards.
1926 After years of continuous assessments, the ACS publishes the first printed manual of hospital standards which contained 18 pages.
1950 Over 3200 hospitals are attaining the minimal standards.
Ernest Amory Codman
Courtesy of Google Images

12. The Joint Commission
1951 After joining of the American college of Physicians, American Hospital Association, an the Canadian Medical Association with the ACS , the Joint Commission on Accreditation of Hospitals (JCAH) is developed.
1952 The ACS transfers the Hospital Standardization Program to JCAH.
1953 JCAH begins to offer accreditation to hospitals and publishes the “Standards for Hospital Accreditation”.
1965 The Social Security Amendment of 1965 states that hospitals receiving accreditation by JCAH will be able to participate in Medicaid and Medicare programs.
1966 JCAH begins to offer accreditation to long term care organizations, thus, starting their expansion across other healthcare disciplines and settings.
1969 Accreditation to organizations serving the disabled.
1970 The standards are changed from the minimal standards of quality to the most optimal achievable quality. Accreditation offered to psychiatric facilities, substance abuse programs, and community mental health.

13. The Joint Commission 1971-present
1975 Accreditation offered to Ambulatory Healthcare.
1979 Accreditation offered to the American Dental Association.
1983 Accreditation offered to Hospice Care Organizations.
1987 Due to the addition of other healthcare disciplines and settings being offered accreditation, JCAH changes their name to Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
1993 The Accreditation Manual for Hospitals is revised to focus on the organizations performance in regards to patients care and hospital function, rather than their ability to perform.
1994 JCAHO goes global forming Joint Commission International which aims to provide consulting on standards.
1995 All of the programs of JCAHO’s focus become performance focused.
2004 Joint Commission International opens offices in Italy.
2006 Offices open in Singapore.
2007 JCAHO shortens name to Joint Commission.
,000 organizations are accredited.

14. JCAHO Established in 1951 It is now called The Joint Commission.
Joint Commission is the largest and most prestigious accrediting agency in Healthcare
Gaining accreditation is not mandatory, but lets the public know that strict levels of performance and safety have been attained.

15. JCAHO
“At a minimum, a hospital must be completely familiar with the current standards, examine current processes, policies and procedures relative to the standards and prepare to improve any areas that are not currently in compliance.”
“To obtain accreditation, healthcare organization staff members must be able to demonstrate proficiency across specific job competencies and receive performance evaluations based on specific job descriptions” (SuccessFactors, 2013).

16. Accreditation
The Joint Commission assesses a health care organization every three years by means of a survey to determine whether it meets certain standards for providing safe and quality care.
Although these surveys are optional, 77% of hospitals nationwide are accredited by JCAHO (Joint Commission, 2013d).
Joint Commission. (2013). Facts about hospital accreditation. Retrieved from

17. Accreditation
Accreditation provides numerous benefits to health care organizations. It helps “strengthen community confidence in the quality of care, provides a competitive edge, improves risk reduction, and provides education for business and staff operations.
It also assists with insurance recognition.” (Joint Commission, 2013a).
Joint Commission. (2013). Benefits of Joint Commission accreditation. Retrieved from

18. Certification
In addition to accreditation, many specialties within an organization seek certification in their areas of expertise as well, but the organization as a whole must have accreditation first.
These specialized programs can become certified in congestive heart failure, transplants, stroke management, diabetes, and asthma, among others. Most certifications need to be renewed every two years (Joint Commission, 2013g).
Joint Commission (2013). What is certification? Retrieved from

19. Certification
The benefits of certification far outweigh the time and effort it takes to seek it. According to JCAHO, the advantages include “improving the quality of patient care, providing a framework for excellence and program structure, and facilitating marketing, contracting, and reimbursements from insurance companies and other third parties” (Joint Commission, 2013b).
Joint Commission. (2013). Benefits of Joint Commission certification. Retrieved from

20. JCAHO National Patient Safety Goals for 2013 (The Joint Commission, 2012)
Reduce the risk of health care-associated infections.
The hospital identifies safety risks inherent in its patient population.
Improve the accuracy of patient identification.
Improve the effectiveness of communication among caregivers.
Improve the safety of using medications.

21. Core Measures
In addition to accreditation and certification, JCAHO also has a set of core measures in place that allows for standardization of care throughout accredited health care organizations. It also assists with insurance reimbursement.
The care sets include: venous thromboembolism, heart failure, substance abuse, acute myocardial infarction, immunizations, emergency department orders, and others (Joint Commission, 2013c).
Joint Commission. (2013). Core measure sets. Retrieved from

22. Mallory Gilbert-Nursing Practice Standards
Every patient that comes onto my unit, which specializes in heart failure, must receive proper education on heart failure. This includes signs and symptoms, weighing themselves everyday, and when to notify their physician of complications. They must also be listed as a heart failure patient within the hospital and be provided with heart failure discharge instructions.

23. Jennifer Discher – Current Practice Standards
My current nursing job is influenced everyday by JCAHO practice standards. JCAHO helps define how we practice as nurses and we are continuously striving to meet and exceed the safety goals. I work on a stroke certified unit and we all must comply with JCAHO standards for stroke care. This means extra certifications and educational hours every year.

24. Shari Hendrickson – Current Practice Standards
In my current practice area of cardiology on a progressive care unit, our staff needs to make sure that our patients that have had heart attacks are discharged with a core group of medications – an aspirin, a beta blocker, an ACE inhibitor, a cholesterol medication, and a platelet aggregator (if they received stents). We need to meet these criteria for each patient to comply with JCAHO standards and their core measures.

25. Derrek Staley – Current Practice Standards
My current area of practice is on a neurology medical-surgical floor. Stroke is the diagnosis that I see most often. In order to comply with the Joint Commissions core measures for stroke, each patient must be individually assessed for the appropriateness of the use antiplatelets (dependent on type of stroke), cholesterol, blood pressure, and antiarrhythmic medications.

26. References
American Health Lawyers Association. (2013). The Joint Commission. Retrieved from JCAHO. (2009). In Mosby’s Medical Dictionary (8th ed). Retrieved from Joint Commission. (2009). The mission statement. Retrieved from Joint Commission. (2012). National patient safety goals effective January 1, Retrieved from Joint Commission. (2013a). Benefits of Joint Commission Accreditation. Retrieved from

27. References cont.
Joint Commission. (2013b). Benefits of Joint Commission certification. Retrieved from Joint commission. (2013c). Core measure sets. Retrieved from Joint Commission. (2013d). Facts about hospital accreditation. Retrieved from Joint Commission. (2013e). History of the Joint Commission. Retrieved from Joint commission. (2013f). The Joint Commission history. Retrieved from

28. References cont.
Joint Commission. (2013g). What is certification? Retrieved from Mallon, W. J. (2013). Codman considered father of evidence-based practice. American Academy of Orthopaedic Surgeons, 7(11). Retrieved from SuccessFactors. (2013). Retrieved from