What Is the TJC Standard?

In the healthcare industry, quality and safety standards play an important role in ensuring that patients receive the best possible care. One such standard that holds significant importance is the TJC Standard.

So, what exactly is the TJC standard in healthcare, where does it come from, and why does it exist? Does your facility really need to meet the Joint Commission quality standards? What’s the point of TJC accreditation?

In this blog, we explore all of these questions and go over the benefits of TJC standards for patient safety to help you have a better understanding of the TJC standard and what it entails. 

What Is The Joint Commission (TJC)? 

The Joint Commission (TJC) is a non-profit organization that sets and issues healthcare accreditation standards in the U.S. 

The organization has gone through several names in its history, but “The Joint Commission” has been a common thread. They began offering accreditation in 1951 and became an official part of the Medicare Conditions of Participation in 1965.

Today, they’re responsible for the accreditation of over 20,000 healthcare programs and organizations, including hospitals, home care services, nursing care centers, behavioral healthcare and addiction services, ambulatory care practices, and lab services.

The Purpose and Importance of TJC Standards 

The Joint Commission quality standards provide healthcare organizations with an objective evaluation process for measuring, assessing, and improving their performance.

TJC focuses largely on patient safety standards and harm prevention. The primary goal is to ensure a safe patient experience by avoiding medical errors and reducing variation in clinical processes.

For healthcare organizations, TJC accreditation has several benefits.

For many healthcare facilities, the primary motive is bureaucratic. It’s a key qualifying step for Medicare certification, allowing organizations to skip other, more redundant quality inspections. In some states, TJC accreditation is also a regulatory requirement. 

Accreditation is also becoming an important part of qualifying for insurance reimbursement or participation in managed care plans and contract bidding.

There are other benefits to complying with TJC’s healthcare accreditation standards. The Joint Commission quality standards help a facility organize and strengthen patient safety and quality of care efforts. Adherence to TJC healthcare standards also reduces the risk of error, which is critical to the financial well-being of a medical service. 

Most directly, these risk management efforts may reduce the cost of liability insurance. Organizations also get access to helpful resources, including education services and tools for measuring performance.

What Are the Joint Commission (TJC) Standards in Healthcare?

TJC has over 250 active quality standards developed with input from healthcare professionals, subject matter experts, consumers, and government agencies, including the Centers for Medicare and Medicaid Services.

TJC is continually evaluating and revising its requirements. Before a new standard is added, TJC considers whether:

• It relates to patient safety or quality of care
• Can have a positive impact on health outcomes
• Meet or surpass existing laws and regulations
• Can be accurately and readily measured

Moreover, TJC standards focus on key areas that ensure quality care and patient safety in healthcare organizations. Here are the primary areas covered:

1. Patient Safety

• Implementation of patient safety goals (e.g., correct patient identification, effective communication).
• Prevention of medical errors, such as falls, wrong-site surgery, and misdiagnoses.
• Safety protocols for high-risk procedures.

2. Infection Control

• Compliance with infection prevention strategies, including hand hygiene, PPE use, and sterilization.
• Monitoring and reporting hospital-acquired infections (HAIs).
• Policies for controlling outbreaks and preventing the spread of infectious diseases.

3. Medication Management 

• Proper storage, labeling, and dispensing of medications.
• Reducing medication errors through standardized administration procedures.
• Safe prescribing practices and patient education on medication use.

4. Emergency Preparedness

• Disaster response planning, including natural disasters and public health crises.
• Staff training for handling mass casualties, power outages, and cybersecurity threats.
• Coordination with local emergency response agencies. 

5. Staff Qualifications and Training

• Credentialing and ongoing education requirements for healthcare providers.
• Training on updated procedures, new technology, and patient safety initiatives.
• Competency assessments to ensure staff meet professional standards. 

6. Patient Rights and Ethics

• Ensuring informed consent and patient privacy.
• Addressing cultural competency and ethical decision-making.
• Protecting patients from abuse, neglect, and discrimination. 

7. Environment of Care 

• Maintaining a safe, clean, and functional healthcare environment.
• Risk assessment for workplace hazards, including fire safety and security.
• Proper disposal of medical waste and hazardous materials. 

8. Performance Improvement

• Continuous monitoring and analysis of healthcare outcomes.
• Implementation of quality improvement initiatives.
• Data-driven decision-making to enhance patient care. 

Differences Between TJC, CMS Requirements and OSHA Standards

The Joint Commission (TJC), the Centers for Medicare & Medicaid Services (CMS), and the Occupational Safety and Health Administration (OSHA) each play distinct but sometimes overlapping roles in regulating and guiding healthcare facilities in the United States. The chart below highlights key differences among these three entities.

CriteriaThe Joint Commission (TJC)Centers for Medicare & Medicaid Services (CMS)Occupational Safety and Health Administration (OSHA)

ScopeFocuses on quality and safety in healthcare organizations through accreditation and performance improvement.Ensures healthcare compliance with federal laws, primarily for facilities receiving Medicare & Medicaid funding.Protects workplace safety by regulating occupational health and safety across industries, including healthcare.

AuthorityPrivate, non-profit accrediting body.Government agency under the U.S. Department of Health & Human Services.Government agency under the U.S. Department of Labor.

Regulatory BasisVoluntary accreditation, but often required for reimbursement and state licensing.Mandatory compliance for Medicare/Medicaid reimbursement.Mandatory compliance for workplace safety.

Focus Areas

• Patient safety
• Quality improvement
• Infection control
• Medication management
• Emergency Preparedness

• Patient rights
• Provider participation requirements
• Reimbursement policies
• Medical necessity & billing compliance
• Infection control

• Workplace safety
• Employee health standards
• Hazardous materials handling
• Bloodborne pathogens
• Personal protective equipment (PPE)

Compliance & EnforcementHospitals voluntarily seek accreditation but risk losing CMS funding if not accredited.Mandatory surveys and audits by State Survey Agencies for Medicare & Medicaid providers.Mandatory workplace inspections, fines, and penalties for violations.

Survey ProcessTriennial on-site surveys, performance reviews, and continuous quality improvement requirements.Surveys conducted by State Survey Agencies on behalf of CMS, with unannounced inspections.Unannounced workplace inspections, with enforcement actions for non-compliance.

Penalties for Non-ComplianceAccreditation loss can impact eligibility for Medicare/Medicaid reimbursement.Fines, payment suspension, exclusion from Medicare & Medicaid programs.Citations, fines, legal penalties, and possible shutdown of operations for severe violations.

Notable OverlapsAligns with CMS regulations for Medicare/Medicaid funding and patient safety.Uses some TJC-accredited hospitals as deemed compliant, reducing inspection frequency.OSHA workplace safety standards influence TJC’s Environment of Care (EOC) standards.

Examples of Key Standards

• National Patient Safety Goals (NPSGs)
• Environment of Care (EOC) Standards
• Infection Control and Prevention

• Emergency Medical Treatment and Labor Act (EMTALA)
• Conditions of Participation (CoPs)
• Hospital Payment Systems

• Bloodborne Pathogens Standard (29 CFR 1910.1030)
• Hazard Communication Standard (29 CFR 1910.1200)
• Respiratory Protection (29 CFR 1910.134)

How to Prepare for TJC Accreditation in Hospitals

The TJC accreditation process has two main components: an objective assessment of the facility’s performance against TJC standards and an unannounced survey that reviews the organization’s processes and functions.

The first step in TJC accreditation is to evaluate compliance with TJC standards by scoring a facility on specific performance elements.

The survey process involves a visit to evaluate an organization’s performance by tracing patient care, reviewing documentation, and observing and interviewing both staff and patients.

There are four potential outcomes for the TJC accreditation process; TJC issues accreditation with: 

1. Full standards of compliance 
2. Conditional accreditation 
3. Provisional accreditation 
4. Preliminary denial of accreditation 

In cases where an organization falls short of full accreditation, they’re given specific time frames for bringing problem areas into compliance.

A full survey is repeated every three years, but 5% of all organizations are selected for random, unannounced surveys each year. 

Get TJC Compliance Training Online 

Staff training is a critical part of adherence to TJC healthcare standards. Not only do some standards explicitly require training, but understanding and being fresh on the particulars of The Joint Commission quality standards are key to individual compliance.

At 360training, we offer online courses on TJC standards that are self-paced and available from any device whenever and wherever your staff has time to squeeze in a little study. It’s an efficient and cost-savvy way to meet TJC healthcare standards. Plus, we’re IACET-accredited, so these courses count toward employees’ CEUs!

Examples of TJC courses in our catalog include:

• Hazard Communications in Healthcare: Covers both OSHA and TJC requirements for chemical hazard communication.
• Abuse and Neglect in the Healthcare Setting: Covers TJC Provision of Care Standard “Victims of Abuse” to ensure staff understanding of the professional responsibility to report abuse.
• Age-Appropriate Care Training: Focuses on age-specific competencies under TJC Provision of Care standards.
• National Patient Safety Goals: Covers TJC’s NPSGs, as well as methods for reducing patient mixups, improving medication safety, and managing risk for healthcare-associated infections and surgical errors.

Our catalog includes other healthcare compliance courses that fulfill HIPAA, OSHA, and other regulatory requirements for one-stop training.

Get started today!