The Joint Commission is an independent, nonprofit organization that evaluates and accredits health care organizations and programs in the United States.
Its primary purpose is to ensure that health care organizations maintain a high level of patient care and safety through rigorous evaluation processes. These evaluations include on-site surveys, during which trained surveyors assess various aspects of health care delivery, including patient care, medication management, infection control and overall organizational performance.
There are 18 chapters within The Joint Commission that evaluate UTMB on more than 270 standards. We also use The Joint Commission for "deemed status" for Centers for Medicare/Medicaid Services.
In order to participate in and receive federal payment from Medicare or Medicaid programs, a health care organization must meet government requirements for program participation, including a certification of compliance with the health and safety requirements called Conditions of Participation or Conditions for Coverage, which are set forth in federal regulations.
The certification is achieved based on either a survey conducted by a state agency on behalf of the federal government, such as the Centers for Medicare & Medicaid Services or by a national accrediting organization, such as The Joint Commission, that has been recognized by CMS (through a process called “deeming”) as having standards that meet or exceed Medicare’s requirements and a survey process that is comparable to the government's.
Health care organizations that achieve Medicare certification through a Joint Commission “deemed status” accreditation survey are determined to meet or exceed Medicare and Medicaid requirements.
Why it matters
The Joint Commission accreditation is crucial for hospitals and health care organizations for several reasons:
Quality assurance: Accreditation by The Joint Commission signifies that a hospital meets or exceeds rigorous standards for patient care and safety. It serves as a mark of quality assurance, reassuring patients and their families that they will receive high-quality care.
Patient safety: The Joint Commission standards are designed to prioritize patient safety. By adhering to these standards, hospitals reduce the risk of medical errors, infections and other adverse events, leading to better outcomes for patients.
Legal and regulatory compliance: Accreditation by The Joint Commission helps hospitals stay compliant with federal and state regulations, as well as with industry best practices. This reduces the risk of legal issues and ensures the hospital operates within established guidelines.
Continuous improvement: The accreditation process involves regular evaluations and assessments, which provide valuable feedback to hospitals. By identifying areas for improvement and implementing necessary changes, hospitals can continually enhance the quality of care they provide.
The Joint Commission accreditation is important because it ensures quality, safety, compliance and continuous improvement in health care delivery, ultimately leading to better outcomes for patients and strengthening the reputation and viability of the hospital.
Consistent commendations for UTMB
UTMB was re-accredited by The Joint Commission in May 2022, our most recent triennial survey. In this survey, we had 56 findings that ranged from a scope of low-limited (majority) to high-widespread (three). We had zero findings that would fall into the scope of immediate threat to life. Thirty-four of the findings were in the Environment of Care and Life Safety chapters.
UTMB has consistently received commendations from surveyors for the exemplary conduct and demeanor of our staff. Surveyors frequently praise our team members for their courteous, engaged, friendly and caring approach.
Their positive feedback underscores the dedication and professionalism of our staff in creating a supportive and welcoming environment for all who enter our facilities. This recognition reflects our commitment to providing not only high-quality health care but also compassionate and person-centered service to everyone we serve.
Room for improvement
We acknowledge that there is room for improvement in our documentation practices within patients’ Electronic Medical Records. It's essential for us to ensure that our documentation aligns with established policies and procedures, allowing us to accurately capture and communicate patient care information.
By enhancing our documentation practices, we can strengthen our ability to provide comprehensive care and facilitate seamless communication among health care team members.
Ensuring that we follow policies is imperative to our success. The Joint Commission surveys provide staff members with an opportunity to showcase their commitment to excellence, learn and grow professionally, collaborate with colleagues, prioritize patient safety and be recognized for their contributions to providing high-quality care.
Achieving The Joint Commission accreditation enhances the reputation of a hospital. It demonstrates a commitment to excellence and continuous improvement, which can attract patients and health care professionals alike.
Everyone has a role
Staff members play a vital role in preparing for and ensuring good outcomes from The Joint Commission surveys by adhering to policies and procedures, maintaining quality documentation, participating in training and education, prioritizing patient safety, fostering communication and collaboration, paying attention to detail, and committing to continuous improvement.
Your dedication and contributions are integral to the hospital's success in meeting The Joint Commission standards and delivering high-quality care to patients.
Megan Cazares is the associate director of accreditation for UTMB and is responsible for directing, implementing and maintaining The Joint Commission and other accreditations and certifications to ensure continual organizational compliance with all applicable standards and readiness for announced and unannounced surveys.
Above, top photo: Leaders from various departments at the Galveston Campus prepare to do readiness rounds in preparation for the upcoming Joint Commission survey.
Middle photo: Angleton Danbury Campus
Bottom photo: League City Campus