Hospital and
Academic Medical
Center Accreditation
Decision Rules
2014
(changes to previous policy highlighted in yellow; new text is underlined, deleted text is struckthough)
I.
ACCREDITATION DECISIONS
INTRODUCTION
The Accreditation Committee considers all information from the initial or triennial full
survey and any required follow-up focused survey in making its decision regarding
accreditation. The outcome is that the organization meets the criteria for accreditation or
does not meet the criteria and is denied accreditation. The criteria for these two potential
outcomes are as follows:
A. ACCREDITED
This decision results when an organization meets all the following conditions:
1. The organization demonstrates acceptable compliance with each standard.
Acceptable compliance is:
 A score of at least “5” on each standard.
2. The organization demonstrates acceptable compliance with the standards in each
chapter. The International Patient Safety Goals are considered a Chapter.
Acceptable compliance is:
 An aggregate score of at least “8” for each chapter of standards.
3. The organization demonstrates overall acceptable compliance. Acceptable
compliance is:
 An aggregate score of at least “9” on all standards.
4. The total number of measurable elements found to be “Not Met” or “Partially
Met” is not above the mean (three or more standard deviations) for organizations
surveyed under the hospital accreditation standards within the previous 24 months.
5. No measureable element in the IPSGs is scored “Not Met.”
B. ACCREDITATION DENIED
This decision results when an organization meets one or more of the following conditions
either 1) at the end of any required focused survey (subsequent to an initial or triennial full
survey) or 2) during the period of accreditation, as a result of a focused survey for the
evaluation of one or more policy-related conditions that may place the organization At
Risk for Denial of Accreditation.* (see below):
1. One or more standard is scored less than a “5.”
2. The aggregate score of one or more chapter of standards is less than an “8.”
3. The aggregate score for all standards is less than “9.”
4. The total number of measurable elements found to be “Not Met” or “Partially Met”
is above the mean (three or more standard deviations) for organizations surveyed
under the hospital accreditation standards within the previous 24 months.
5. One or more measurable element in the IPSGs is scored “Not Met.”
6. A required focused survey subsequent to an initial or triennial full survey has not
resulted in acceptable compliance with applicable standards.
1
Approved by JCI Accreditation Committee 28 August 2013
For External Customers
Hospital and
Academic Medical
Center Accreditation
Decision Rules
2014
(changes to previous policy highlighted in yellow; new text is underlined, deleted text is struckthough)
7. One or more of the conditions that place the organization At Risk for Denial of
Accreditation* have not been resolved at the time of the focused survey to evaluate
the condition.
8. The organization voluntarily withdraws from the accreditation process.
9. The organization does not permit the performance of any survey by Joint Commission
International.
*Conditions that place an organization At Risk for Denial of Accreditation are the following:
1. An immediate threat to patient/public health or staff safety exists within the organization.
2. An individual who does not possess a license, registration, or certification is providing or has provided health
care services in the organization that would, under applicable law or regulation, require such a license,
registration, or certification and which placed the organization’s patients at risk for a serious adverse outcome.
3. Joint Commission International is reasonably persuaded that the organization submitted falsified documents or
misrepresented information in seeking to achieve or retain accreditation, as required by the Information
Accuracy and Truthfulness Policy.
4. A number of not compliant standards (Not Met or Partially Met) at the time of survey is above the mean (three
or more standard deviations) for organizations in the same program surveyed during the previous 24 months.
5. The organization does not possess a license, certificate, and/or permit, as, or when, required by applicable law
and regulation, to provide the health care services for which the organization is seeking accreditation.
6. The organization has not met the accreditation policy for “Reporting Requirements between Surveys.”
7. The organization fails to submit an acceptable Strategic Improvement Plan (SIP) within 120 days of the
organization’s survey.
2
Approved by JCI Accreditation Committee 28 August 2013
For External Customers