Accreditation Approval

Citation

TJC APR.01.01.01

The hospital submits information to Joint Commission as required.

The hospital must submit required data and information to The Joint Commission in a timely manner to maintain accreditation.

Citation

TJC APR.01.02.01

The hospital provides accurate information throughout the accreditation process.

The hospital is required to provide accurate information to The Joint Commission throughout the accreditation process and is prohibited from falsifying records.

Citation

TJC APR.01.03.01

The hospital reports any changes in the information provided in the application for accredita...

The hospital must notify The Joint Commission within 30 days of significant organizational changes and immediately upon notice of loss of deemed status from CMS.

Citation

TJC APR.02.01.01

The hospital permits the performance of a survey at Joint Commission's discretion.

The hospital must permit The Joint Commission to conduct surveys at its discretion.

Citation

TJC APR.04.01.01

The hospital selects and uses performance measures from among those available that are releva...

The hospital must select and report relevant performance measures to The Joint Commission to meet ORYX requirements.

Citation

TJC APR.05.01.01

The hospital allows Joint Commission to review the results of external evaluations from publi...

The hospital must provide The Joint Commission with access to official records and reports from other licensing or reviewing bodies upon request.

Citation

TJC APR.06.01.01

Applicants and accredited hospitals do not use Joint Commission employees to provide accredit...

Hospitals are prohibited from using Joint Commission employees for accreditation-related consulting services.

Citation

TJC APR.07.01.01

The hospital accepts the presence of Joint Commission surveyor management staff or a Board of...

The hospital must allow Joint Commission management or Board members to observe on-site surveys.

Citation

TJC APR.08.01.01

The hospital accurately represents its accreditation status and the programs and services to...

The hospital must accurately represent its accreditation status and the specific services covered by that accreditation in all advertising.

Citation

TJC APR.09.01.01

The hospital notifies the public it serves about how to contact its hospital management and J...

The hospital must inform the public how to contact hospital management and The Joint Commission to report concerns regarding patient safety and quality of care.

Citation

TJC PC.13.01.01

The hospital plans operative or other high-risk procedures.

Requires the hospital to plan operative and high-risk procedures and to ensure anesthesia is administered only by specified qualified practitioners.

Citation

TJC RC.11.03.01

The hospital retains its medical records.

Establishes that the hospital retains medical records in accordance with law, regulation, and hospital policy, with a five-year retention floor for deemed-status hospitals.

Citation

TJC RI.12.01.01

The hospital respects the patient's right to participate in decisions about their care, treat...

Requires the hospital to respect and support the patient's right to participate in care decisions, including informed decisions, notification of admission, and advance directives.

Citation

TJC RI.12.02.01

The hospital respects the patient's right to receive information about the individual(s) resp...

Requires the hospital to inform the patient of the names of the licensed practitioners responsible for and providing the patient's care, treatment, and services.

Citation

TJC RI.13.01.01

The patient has the right to be free from harassment, neglect, exploitation, and verbal, ment...

Requires the hospital to protect patients from abuse, neglect, exploitation, and harassment, and to report allegations to appropriate authorities within specified time frames.

Citation

TJC RI.14.01.01

The patient and their family have the right to have grievances reviewed by the hospital.

Establishes the patient's and family's right to have grievances reviewed by the hospital, including required grievance resolution policies, time frames, and written notice of decisions.

Citation

TJC TS.11.01.01

The hospital, with the medical staff’s participation, develops and implements written policie...

Requires the hospital, with medical staff participation, to develop and implement written policies and procedures for donating and procuring organs, tissues, and eyes, including OPO and tissue/eye bank agreements, donor family notification, and documentation of donation decisions.

Citation

TJC TS.12.01.01

The hospital complies with organ transplantation responsibilities.

Requires hospitals performing organ transplants to comply with OPTN rules and provide required transplant data to designated entities.