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Cibola General Hospital is Accredited by The Joint Commission

Facts about Hospital Accreditation

The Joint Commission has accredited hospitals for more than 50 years and today it accredits approximately 4,167 general, children’s, long term acute, psychiatric, rehabilitation and surgical specialty hospitals, and 373 critical access hospitals, through a separate accreditation program. Approximately 82 percent of the nation’s hospitals are currently accredited by The Joint Commission.

Eligibility

Any health care organization may apply for Joint Commission accreditation under the Hospital Accreditation Standards if all the following requirements are met:

• The organization is in the United States or its territories or, if outside the United States, is operated by the U.S. government, under a charter of the U.S. Congress.
• The organization assesses and improves the quality of its services. This process includes a review of care by clinicians, when appropriate.
• The organization identifies the services it provides, indicating which services it provides directly, under contract, or through some other arrangement.
• The organization provides services addressed by the Joint Commission’s standards.
• If the organization uses its Joint Commission accreditation for deemed status purposes, the organization meets the Centers for Medicare & Medicaid Services definition of a “hospital.”

Benefits of accreditation

Hospitals seek Joint Commission accreditation because it:

• Helps organize and strengthen patient safety efforts.
• Strengthens community confidence in the quality and safety of care, treatment and services.
• Provides a competitive edge in the marketplace.
• Improves risk management and risk reduction.
• May reduce liability insurance costs.
• Provides education on good practices to improve business operations.
• Provides professional advice and counsel, enhancing staff education.
• Provides a customized, intensive review.
• Enhances staff recruitment and development.
• Provides deeming authority for Medicare certification.
• Recognized by insurers and other third parties.
• Provides a framework for organizational structure and management.
• May fulfill regulatory requirements in select states.

Standards

Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment. The Joint Commission develops its standards in consultation with health care experts, providers and researchers, as well as measurement experts, purchasers and consumers. For 2009, the standards-based performance areas for hospitals are:

• Environment of Care
• Emergency Management
• Human Resources
• Infection Prevention and Control
• Information Management
• Leadership
• Life Safety
• Medication Management
• Medical Staff
• National Patient Safety Goals
• Nursing
• Provision of Care, Treatment, and Services
• Performance Improvement
• Record of Care, Treatment, and Services
• Rights and Responsibilities of the Individual
• Transplant Safety
• Waived Testing

Survey process

To earn and maintain accreditation, a hospital must undergo an on-site survey by a Joint Commission survey team. The survey team can include one or more health care professionals, including a physician, nurse, life safety code specialist, or hospital administrator who has senior management level experience. Joint Commission surveys are unannounced, with a few exceptions, such as with Department of Defense facilities. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. For example, if an organization’s last survey was January 1, 2009, it could have its survey as early as July 1, 2010 or as late as April 1, 2012 (18 to 39 months). A survey is designed to be individualized to each organization, to be consistent, and to support the organization’s efforts to improve performance. During an accreditation survey, The Joint Commission evaluates an organization’s performance of functions and processes aimed at continuously improving patient outcomes. This assessment is accomplished through evaluating an organization’s compliance with the applicable standards in the manual, based on the following:

• Tracing the care delivered to patients
• Verbal and written information provided to The Joint Commission
• On-site observations and interviews by Joint Commission surveyors
• Documents provided by the organization

Performance measurement requirements

The Joint Commission’s ORYX® initiative integrates outcomes and other performance measurement data into the accreditation process. ORYX measurement requirements are intended to support Joint Commission accredited organizations in their quality improvement efforts. In 2002, accredited hospitals began collecting data on standardized-or “core”-performance measures. In 2004, The Joint Commission and the Centers for Medicare & Medicaid Services began working together to align measures common to both organizations. These standardized common measures, called “Hospital Quality Measures,” are integral to improving the quality of care provided to hospital patients and bringing value to stakeholders by focusing on the actual results of care. Measure alignment benefits hospitals by making it easier and less costly to collect and report data because the same data set can be used to satisfy both CMS and Joint Commission requirements.

Hospital information available to the public

Information about the safety and quality of accredited hospitals is available to the public at Quality Check®, www.qualitycheck.org. This comprehensive listing includes each accredited hospital’s name, address, telephone number, accreditation decision, current accreditation status and effective date, and its Quality Report. Quality Reports include detailed information about a hospital’s performance and how it compares to similar hospitals.

Cost of accreditation

Annual fees are based on the size and the service complexity of individual hospitals and range from $1,780 to $36,845. For 2010, the on-site survey fees for hospitals are: $2,500 per surveyor for the first day and $1,030 per surveyor for the second and subsequent days. For small hospitals (those with fewer than 26 beds and less than 50,000 visits), the 2010 annual fee is $1,090 and the on-site survey fees are $4,580 per survey. The on-site survey fee is paid at the beginning of the year in which the on-site survey will be conducted, along with the annual fee, and covers survey-related direct costs. Organizations have the option to receive a corporate orientation or corporate summation. These can be conducted by the entire survey team, by the team leader only, or by Central Office staff. The Joint Commission extranet includes a fee calculator to help estimate annual subscription billing costs. For more information about pricing, including a weighted volume worksheet for annual fees, contact The Joint Commission’s Pricing Unit at pricingunit@jointcommission.org or 630-792-5115.

For more information

For questions about standards, contact the Standards Interpretation Group at standards@jointcommission.org or 630-792-5900. For questions about hospital accreditation services, call 630-792-3007. Corporate offices for systems of accredited organizations (i.e. multi-hospital systems in all states) should call 630-792-5778.