The Joint Commission Overhauls Care Accreditation Standards: What This Means for Nurses

• The Joint Commission has implemented several changes in 2023 that impact nurses and patient care.
• Additions were made to address healthcare disparities in January 2023, and 168 standards were eliminated in July 2023.
• The Joint Commission created a new Health Care Equity Certification program and is part of a one-year mentorship program, the Advancing Equity Through Quality and Safety Peer Network.

The Joint Commission announced changes to accreditation standards in December 2022. The revisions included accreditation for hospitals, ambulatory care centers, behavioral healthcare, and nursing care centers.

This announcement was the first of several that affect Joint Commission standards, which have implications for nursing care. Let's examine the changes and what this could mean for nurses in the coming months.

About Joint Commission Standards

Joint Commission standards are developed using input from healthcare experts. They are an objective means of evaluating care with the goal of improving performance and patient outcomes.

Hospitals actively pursue accreditation from The Joint Commission to receive payment from federally-funded programs like Medicaid and Medicare. Other healthcare organizations, like surgical centers, home health services, and physician offices, also earn Joint Commission accreditation, which also affects payments.

Healthcare facilities must pass Joint Commission evaluations to receive accreditation, awarded after a successful on-site survey. Joint Commission surveyors randomly select medical records to trace a patient's experience within the facility.

Surveyors also observe healthcare professionals in the performance of their duties. In most cases, a Joint Commission accreditation is a three-year award. The Joint Commission accredits and certifies over 23,000 healthcare facilities and performs 10,000 or more surveys each year.

In addition to needing Joint Commission accreditation to receive federal payments, hospitals seek accreditation to help decrease costs, which are reduced by improved risk management practices. Joint Commission accreditation is also an important professional recognition and indicator that the facility provides high-quality care.

The Joint Commission Revises Additional 200+ Standards

The first round of revisions were effective January 1, 2023. They were developed to help reduce healthcare disparities within an organization, many of which became glaringly obvious during the COVID-19 pandemic.

The new standard has six elements of performance that The Joint Commission developed as critical quality and safety standards. The proposal was issued in June 2022, with implementation on January 1, 2023. Some of the performance elements in the new standards include:

• A designated individual to lead activities aimed at reducing healthcare disparities.
• A written action plan describing how the organization will address at least one of the healthcare disparities identified in the patient population.
• An annual report to leaders, practitioners, and key stakeholders about the organization's progress in reducing identified healthcare disparities.

In December 2022, The Joint Commission also announced it was eliminating 168 standards and revising 14 others. The revisions were effective January 1, 2023, eliminating 56 standards for hospitals, 37 for critical access hospitals, 20 for ambulatory healthcare, and more for behavioral healthcare, home care, lab services, and nursing care centers.

The Joint Commission reviewed standards based on several questions, including whether the requirement addresses an important quality and safety issue or is redundant. The second set of standard changes became effective in July 2023 for hospital programs. The Joint Commission identified 16 goals in the new standard changes, including:

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among caregivers
• Improve medication safety
• Reduce the risk of hospital-acquired infections
• Identify safety risks inherent in the facility's population
• Improve healthcare equity

The changes in the first six months of 2023 also included a voluntary Health Care Equity Certification program. The certification focuses on addressing systemic health inequities and racism in the role that hospitals and health systems play to support sustained equity.

The certification program aims to formalize structures and processes for organizations on a path to healthcare equity. Alongside the certification, The Joint Commission is also a part of the Advancing Equity Through Quality and Safety Peer Network, a one-year program led by the American Medical Association, The Joint Commission, and Brigham and Women's Hospital.

The mentorship program teaches health systems how to incorporate racial justice and equity into safety practices. Currently, eight health systems are participating, including the Dana-Farber Cancer Institute and Vanderbilt University Medical Center.

What Joint Commission Standards Mean for Nurses and Patient Care in 2023 and Beyond

Nurses play a key role in the accreditation process in hospital systems and within The Joint Commission. Mark Pelletier, chief operating officer and chief nurse executive of The Joint Commission, wrote that the commission employs more than 250 nurses to help interpret standards and requirements while working on quality initiatives.

It's not uncommon for healthcare professionals to fear The Joint Commission accreditation process. Yet the commission is dedicated to partnering with organizations to improve quality of care. The voluntary accreditation demonstrates the organization's willingness and desire to meet accreditation standards.

Nurses play an important role leading up to the survey process in developing institution-wide policies and procedures that help meet Joint Commission standards. Organizational teams must also recognize and implement new Joint Commission standards in 2023. These standards must be communicated through nursing leadership to bedside nurses, which ultimately impacts patient care.

Staff development plays a strong role in educating the bedside nurse about quality standard changes that impact patient care at the bedside. Many new Joint Commission standard changes will first impact organizational teams accountable for designing procedures to improve safety, communication, and healthcare equity.