Accreditation Categories

Joint Commission Categories of Accreditation

The Joint Commission scores hospitals on their compliance with each standard. The scores are combined, and along with surveyor observances, are used to determine accreditation status. Current categories of accreditation include the following:

Accreditation with Full Standards Compliance is awarded to hospitals that meet standards in all performance areas.

Accreditation with Requirements for Improvement is awarded to hospitals that meet most standards, but may have some areas where improvement is necessary. Problems identified must be corrected within a specified time period.

Provisional Accreditation is based on results of a partial survey done for hospitals that are new to the accreditation process. This designation remains in effect until a full survey takes place and one of the other accreditation categories can be assigned.

Conditional Accreditation is given to hospitals that don't meet standards in important ways and are performing only marginally. The Joint Commission gives these facilities the opportunity to correct any problems and then may do another survey to see if sufficient improvement is noted.

Preliminary Denial of Accreditation is given when a hospital fails to or is persistently unable or unwilling to comply with the Joint Commission's requirements in multiple areas, but is believed capable of coming into compliance within a stipulated time period.

Accreditation Denied is the status for hospitals that fail to meet Joint Commission standards. It becomes effective when all appeal procedures have been exhausted.

A hospital may also be placed on Accreditation Watch. This designation is given on top of a hospital's existing accreditation status. It's announced when something happens at the hospital that leads to the death or serious injury of a patient, or when the risk of such an event is present. The designation remains in effect until the hospital investigates the situation and develops an acceptable plan for correcting it or preventing it from happening again.

Finally, some hospitals may also have the status of Accreditation with Commendation. This designation was given to hospitals that have full compliance with the Joint Commission's standards. Although the category was discontinued as of Jan. 1, 2000, hospitals that received the designation in 1999 are eligible to retain it until their next complete survey.

In addition to scheduled surveys, the Joint Commission conducts unannounced surveys when complaints raise serious concerns about a continuing threat to patient safety or if a hospital continuously fails to comply with standards. The Joint Commission also conducts random, unannounced surveys every year in 5 percent of the facilities it accredits to make sure hospitals remain in compliance.