Seeking and Maintaining Joint Commission Accreditation

Image of hospital staff interacting with Joint Commission Accreditation representative
Editorial Staff | September 18, 2017

If you’re in the healthcare industry, you know how important it is to gain and maintain Joint Commission accreditation, formerly known as JCAHO accreditation. The goal of the Joint Commission is to continuously improve the safety and quality of healthcare institutions and the level of service they provide to the public. While accreditation is not mandatory, in this day and age, it is necessary for healthcare facilities and laboratories to earn and maintain Joint Commission accreditation in order to stay competitive. Joint Commission accreditation leads to better quality recruitment and development, gives your organization legitimacy by acknowledging that high standards and quality are met, increases recognition by insurers and third parties and, in some states, fulfills regulatory requirements.

Earning & Maintaining Joint Commission Accreditation

Although obtaining accreditation is a rigorous process, you can receive assistance for your organization by visiting and applying for the appropriate accreditation. Each type of institution, health service provider or laboratory is required to meet its own set of standards as laid out by the Joint Commission. For initial accreditation, healthcare organizations will need to prove proficiency in several key areas and meet compliance standards. In order to prepare for inspection, it is recommended that organizations conduct an internal audit by either assigning a team of in-house experts or hiring a third-party expert to identify and remedy any areas that don’t meet compliance standards. An inspector will perform a thorough evaluation of quality and safety processes and report any concerns or areas that could stand in the way of obtaining accreditation. Earning accreditation could take anywhere from two weeks to several months from the initial survey.

Surveys can vary depending on the type of organization or laboratory. All surveys follow a basic outline, and during your survey you should expect the following events:

  • Survey-planning session
  • Opening conference and orientation to the organization
  • Leadership session
  • Tracer methodology to use as the framework for assessing standards compliance
  • Competence assessment process
  • Medical staff credentialing and privileging (hospitals only)
  • Environment of care session
  • Exit conference, during which the survey team presents a written summary of the survey findings

Once accreditation is received, it is important to maintain safety and quality standards as outlined by the Joint Commission. To maintain accreditation, inspectors conduct unannounced surveys every three years except in the case of laboratories, where accreditation is only valid for two years.

Your individual inspector may focus on a number of different safety and compliance areas. Our experiences suggest that the following areas are often identified during a typical inspection:

  • Safe Cylinder Storage—Cylinders must be in storage racks or chained to wall brackets. See your Authority of Jurisdiction for specific storage volume limitations and proximity to flammables and heat source limitations
  • Cylinder Transportation—Small cylinders for transport patients should be maintained in a cart or rack
  • Cylinder Segregation—Cylinders must be segregated and storage clearly labeled as either full or empty
  • Bulk Oxygen Storage Systems—See your Authority of Jurisdiction for specific installation and backup storage requirements
  • Medical Oxygen Piping & Manifold Systems—See your Authority of Jurisdiction for specific requirements for validation and annual inspection

A Team Effort

Earning Joint Commission accreditation for your organization or program is team effort. As mentioned above, there are many aspects to the survey and your vendors—your suppliers and service providers—may have been through this process before. Troy Fowler, Director of Total Gas Management Services at Airgas, an Air Liquide company, emphasizes the importance of leaning on your vendors for help with accreditation. Chances are your vendors have been asked to address similar issues with other organizations and can help to identify areas of focus and safe storage solutions. Leverage their experience to help you find solutions for maintaining the high quality standards and safety requirements outlined by the Joint Commission so you can focus on what matters most: high-quality patient care.

What is the Joint Commission, formerly known as JCAHO?
JCAHO stands for the Joint Commission on the Accreditation of Healthcare Organizations, which was recently renamed to the Joint Commission. The Joint Commission is an independent, non-profit organization that was founded in 1951 and is now the nation’s oldest and largest accrediting body in healthcare. Today they accredit and certify more than 21,000 healthcare institutions and programs in the United States, including hospitals and organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory and nursing care center services.

What’s the difference between an accreditation and a certification?
Accreditations are earned by the entire organization (hospitals, nursing homes, office-based surgery practices, home care providers, and laboratories), whereas certifications are granted to specific programs within a healthcare organization.


Continuing to build on a career that spans over two decades, Troy Fowler serves as Airgas’ Director of Medical Gas Services. With a keen understanding of the market and a disarming sense of humor, Troy helps healthcare providers address their gas supply concerns.

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