Chapter 10 - Terminologies & Concepts

An independent, not for profit organization that is the most predominant standard-setting and accrediting body in healthcare in the United States. Type your answer in all-caps letters.

The process by which an organization measure the quality of each services and performance against nationally required standards. Type your answer in all-caps letters.

Measures that address an organizational's level of performance in key functional areas including patient rights and treatment and infection control.

• Elements of Performance (The Joint Commission)

• Evidence of Standards Compliance (The Joint Commission)

• Standards (The Joint Commission)

• Accreditation (The Joint Commission)

Specific performance expectations that must be in place for an organization to provide safe, high quality care, service, and treatment.

• Standards (The Joint Commission)

• Elements of Performance (The Joint Commission)

• ORYX (The Joint Commission)

• Hospitality Quality Measures (The Joint Commission)

The accreditation decision awarded to a healthcare organization in compliance with all standards at the time of the on-site survey or that has addressed requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 or 60 days following posting of the Accreditation Finding Summary Report.

• Conditional Accreditation (The Joint Commission)

• Provisional Accreditation (The Joint Commission)

• Evidence of Standards Compliance (The Joint Commission)

• Accreditation (The Joint Commission)

An electronic, extranet-based report submitted by a surveyed organization in response to Requirements for Improvement (Not Compliant Standards)

• Evidence of Standards Compliance (ESC): The Joint Commission

• Professional Accreditation (The Joint Commission)

• Provisional Accreditation (The Joint Commission)

• Conditional Accreditation (The Joint Commission)

This report details the action(s) at the Elements of Performance level that the organization has taken to comply with the standards or to clarify why it believes it was in compliance with the standards at the time of survey.

• Elements of Performance (The Joint Commission)

• Preliminary Accreditation (The Joint Commission)

• Evidence of Standards Compliance (ESC): The Joint Commission

• Provisional Accreditation (The Joint Commission)

Results when a healthcare organization fails to successfully address all requirements for improvement in an Evidence of Standards Compliance (ESC) within 45 or 60 days following the posting of the Accreditation Findings Summary Report.

• Conditional Accreditation (The Joint Commission)

• Provisional Accreditation (The Joint Commission)

• Preliminary Denial of Accreditation

• Preliminary Accreditation

Results when a healthcare organization was in Preliminary Denial of Accreditation, or the organization failed to resolve the requirements of the Provisional Accreditation; or it was not in substantial compliance with the applicable standards.

• Provisional Accreditation (The Joint Commission)

• Preliminary Accreditation

• Accreditation (The Joint Commission)

• Conditional Accreditation (The Joint Commission)

Results when there is justification to deny accreditation as evidenced by an Immediate Threat to Health or Safety Situations; or an organizations failed to resolve the requirements of conditional accreditation; it was in significant noncompliance with Joint Commission Standards.

• Preliminary Denial of Accreditation

• Conditional Accreditation

• Provisional Accreditation

• Preliminary Accreditation