Medical Facilities Unit

Hospital Licensing Reform Steering Committee

(Microsoft Word*)  (Adobe PDF*)

Joint Commission Presentation: Potential Questions for Discussion

  • How does the Joint Commission use data to inform the survey process? What data do you look at? How is data used to determine priority focus areas?
  • Can you walk through the process of analyzing data, deciding what to prioritize for tracer areas, and how the tracer methodology works while you are on-site? How is the experience for surveyors different when using tracer methodology as compared to the standard methodology?
  • Do other states align the Joint Commission survey process with their own licensing survey (e.g., participate or observe)? If so, how does that work?
  • How do states align licensing status with the Joint Commission survey process?
  • What kind of variation is there in how states deem Joint Commission accreditation?
  • What standards do states typically deem? Are there particular areas that states tend to survey themselves, even if they deem for others?
  • Does the Joint Commission ever survey for certain standards on behalf of the state?
  • Does the Joint Commission ever share oversight of a hospital with a state when there is a provisional deficiency?
  • When a state deems based on JC accreditation, what typically happens to the Joint Commission’s findings? Are they fully disclosed to the state? The public?
  • Do other states look behind the Joint Commission survey process?