Are organizations only held accountable to Joint Commission standards?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

The Joint Commission evaluates health care organizations’ compliance with The Joint Commission standards. However, The Joint Commission also evaluates health care organizations’ compliance with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and other applicable federal, state, and local laws and regulations. Additionally, The Joint Commission evaluates organizations’ adherence to their own internal organizational policies and procedures developed and implemented to meet regulatory standards.^1,2

The Joint Commission also holds organizations accountable to manufacturer’s instructions of use and evidence-based performance standards chosen by the organization, which are intended to improve quality and safety. It is left to the discretion of individual organizations to establish policies to meet Joint Commission standards and other requirements. The Joint Commission then holds organizations accountable to following their own policies.¹

Over-interpretation or misinterpretation of required standards for Joint Commission accreditation may lead to overly strict policies, unnecessary tasks, and inefficient processes. Health care organizations may establish internal requirements well beyond Joint Commission standards. When health care organizations fall short of these more stringent, self-imposed policies and procedures, they risk being surveyed by The Joint Commission as out of compliance.

“Organizations frequently establish stringent requirements well beyond our standards, and they then get scored as being out of compliance. We get blamed for this, and that’s how myths arise that we require things when we do not!”

—David Baker, MD, MACP, executive vice president, healthcare quality evaluation and improvement, The Joint Commission

• Activities of The Joint Commission H-220.939

• The Joint Commission Accreditation Process Overview Fact Sheet
• Download this myth: Adherence to Joint Commission Standards (PDF)

1. The Joint Commission. Learn the Accreditation Process. The Joint Commission. Published 2023. Accessed November 10, 2023. https://www.jointcommission.org/what-we-offer/accreditation/become-accredited/learn-the-process/
2. The Joint Commission. Accreditation Process Overview Fact Sheet. The Joint Commission. Published 2023. Accessed November 10, 2023. https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-accreditation-process-overview/

Visit the overview page for information on additional myths.

Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.