TJC approved as hospital AO for only two years this time

Hospital Safety Insider, July 23, 2020

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By A.J. Plunkett (

The Joint Commission (TJC) again has earned CMS approval as a national accrediting organization (AO) for hospitals, but only for two years.

The last time TJC was renewed as a hospital AO was in 2014, for a six-year period. That ran out as of July 15, 2020.

In a special filing in the July 15, 2020, Federal Register, CMS published a notice that TJC had been approved as a hospital AO through July 15, 2022.

The federal announcement made note that the approval was only two years, instead of the six years maximum allowed by regulation.

“This shorter term of approval is based on our concerns related to the comparability of TJC’s survey processes to those of CMS, as well as what CMS has observed of TJC’s performance on the survey observation. Some of these concerns stem from the level of detail TJC provides in the daily briefings it provides to facilities, as well as TJC’s processes surrounding its staff interview practices. Additionally, we are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment Condition of Participation (CoP),” said CMS.

In the last few months, TJC has revised or expanded standards to meet CMS demands. Among other things, according to the notice, TJC also revised surveyor training and required the AO to provide more information to hospitals during the survey’s daily briefing.

CMS said it remains “concerned about the thoroughness of review conducted within the facilities.” The agency acknowledged all the changes TJC has made, but “we will continue ongoing review of TJC’s survey processes across all their approved accrediting programs to ensure that all our recommended changes have been implemented. In keeping with CMS’s initiative to increase AO oversight, and ensure that our requested revisions by TJC are complied with, CMS expects more frequent review of TJC’s activities to avoid any continued inconsistencies.”

In a statement, Mark R. Chassin, MD, FACP, MPP, MPH, TJC's president and chief executive officer, promised his organization would work with CMS on continuing to improve patient safety.

“The Joint Commission is pleased that the Centers for Medicare & Medicaid Services (CMS) recognizes the value of continuing to grant hospital deeming authority to The Joint Commission. The deeming authority designation allows The Joint Commission to evaluate our nation’s hospitals for compliance with CMS health and safety requirements, while also surveying for adherence to our own rigorous quality performance standards. All issues raised by CMS about comparability of our respective processes were adjudicated during the deeming authority application process, as noted in CMS’ public notice granting approval of our application," said the statement.

“The Joint Commission appreciates that CMS began an initiative last year to increase its oversight of all hospital accrediting organizations. We will continue to demonstrate that Joint Commission accreditation provides the nation’s most state-of-the art and effective evaluation of hospitals. We look forward to our ongoing work with CMS to improve patient safety and quality of care.”

For several years, CMS has cracked down on TJC and all the AOs, even separating out a performance report on AOs to Congress that had previously been part of the agency’s annual financial report.

Then in December 2018, CMS issued a request for comment on possible conflicts of interest by AOs that also offered consulting services for a fee.

In February of this year, CMS sent the Office of Management and Budget a proposed rule to review on “Strengthening Oversight of Accrediting Organizations (AO) and Related Provisions.” While that proposal was expected to be published in the spring, it still is before the OMB, presumably backlogged because of the coronavirus pandemic.


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