Accreditation Guide for Hospitals - Joint （认证指南医院联合）.pdf

A ccreditation Guide f or Hosp itals Dear Colleague, Thank you for looking to The Joint Commission when it comes to your accreditation needs. Joint Commission recognition is a visible demonstration to your patients, their families, your staff and the community of your commitment to the highest level of safety and quality. The Accreditation Guide for Hospitals is designed to help you learn about the Joint Commission’s accreditation process. This guide provides information about several important areas including eligibility, how to request accreditation and prepare for the process, the on-site survey process, and accreditation decisions. We hope that you will find this guide helpful in understanding the accreditation process. If you have questions, or would like to speak with someone directly, please contact me. Sincerely, Mark Pelletier Executive Director, Mark Pelletier, RN, MS Interim Chief Operating Officer, Accreditation and Certification Operations 630-792-5755 mpelletier@ 2 Table of Contents Telephone and Website Directory 5 Hospital Resources 6 Joint Commission Snapshot Introduction 7 Our Mission 7 The Joint Commission: Who Are We? 7 Why Choose The Joint Commission? 7 What Types of Facilities are Eligible for Hospital Accreditation? 8 Standards, Goals and Survey Process The Standards Manual 9 Patient-Focused Functions 9 Organization Functions 9 The Joint Commission Patient-Centered Accreditation Process 11 Tracer Methodology 11 Priority Focus Process 11 Evidence of Standards Compliance 12 Performance Measurement Requirements