Joint Commission - Frequently Asked Questions

Who can I contact if I have a question about a standard or surveyor's interpretation of a standard? 

If you do not find the answer you are looking for here, the Joint Commission has a page of standards clarifications on the Comprehensive Accreditation Manual for Hospitals (CAMH), please visit You can contact ACEP staff in the Emergency Medicine Practice Department concerning Joint Commission standards. Staff can provide you with information about the standards, current issues being address by PTAC representatives, input received from other members and can submit questions to JCAHO for you. You can also submit questions directly to the Joint Commission. 

Moderate Sedation Medication and Patient Monitoring

Question: Does the Joint Commission define what medications are considered under the standards for moderate or deep sedation? 

The Joint Commission standards do not specify specific medications that moderate or deep sedation standards apply. If the medication is used for inducing moderate or deep sedation the standards apply.

Question: Does the person administering sedation have to be qualified to monitor the patient if other staff who are present are qualified? 

Standard PC.13.20 states, "Sufficient numbers of qualified staff (in addition to the individual performing the procedure) are present…" to evaluate, monitor, administer medication, assist with the procedure if needed and recover the patient.

Permission to Administer Moderate Sedation

Question: Are specific privileges to administer moderate sedation required? 

Standard PC.12.20 EP 4 states that "Individuals administering moderate or deep sedation are qualified and have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved…" It is up to the organization to determine the qualifications and credentials that are required. A number of methods to demonstrate competency have been suggested such as ACLS certification, an exam, or a simulation of a rescue but the Joint Commission does not mandate how this is to occur. For an emergency physician it is not required that moderate sedation be included as a separately delineated privilege. For an emergency nurse this could be included as part of the job description.

National Patient and Safety Goals

Question: What are the 2007 National Patient Safety Goals? 

On June 2, 2006, the Joint Commission's Board of Commissioners approved the 2007 National Patient Safety Goals (NPSGs). A list of the 2007 National Patient Safety Goals is available at the following link on the JCAHO web site. 


Question: Does the Joint Commission have a list of abbreviations that can not be used? 

Yes. The list of "do not use" abbreviations is available at the following link on the JCAHO web site. 


Question: Does Joint Commission require medication reconciliation in the ED? 

Patient Safety Goal 8 states "Accurately and completely reconcile medications across the continuum of care." The only time reconciliation would not be required for a patient seen in the ED is when there are no medications ordered, the patient is not admitted and the hospital has determined that reconciliation is not required in that circumstance.

The American College of Emergency Physicians (ACEP), the American Academy of Emergency Medicine (AAEM), and the Emergency Nurses Association (ENA) submitted comments to the Joint Commission (PDF) regarding the Medication Reconciliation standard MM 4.10 and 2006 National Patient Safety Goal number 8, which is: "Accurately and completely reconcile medications across the continuum of care." May 30, 2006

The Joint Commission Sentinel Event Alert Issue 35 - January 25, 2006 addresses medication reconciliation and clearly states that it does apply to the emergency department. 

Question: Does Joint Commission require ACLS or related resuscitative certifications for physicians? 

The Joint Commission does not require ACLS or related resuscitative certification. They specify that there is "a process for granting, renewing, or revising setting specific clinical privileges …. And that there is evidence of current competence..." within the scope of privileges being requested. The evidence of current competence is not specified by the Joint Commission.

Question: Does Joint Commission require pharmacy staff on-site 24/7? 

The Joint Commission does not require pharmacy staff on site 24/7 but they do have standards that restrict access to the pharmacy if a pharmacist is not present. When a patient requires a medication on an urgent or emergent basis and the pharmacy is not open the hospital must have a process for providing medication to meet their needs. Part of this process would include access for "trained designated" staff to a "limited set of medications that have been approved by the hospital" In addition to limited access, quality control procedures must be in place to prevent medication retrieval errors and a pharmacist must be available to answer questions or provide medications not available to non-pharmacy personnel.

Question: Does the Joint Commission require a pharmacist to review all medications prior to administration to a patient in the emergency department? 

In non-urgent situations the Joint Commission does require review by a pharmacist of all prescription or medication orders unless a "licensed independent practitioner controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the patient…" This is being interpreted to mean that the LIP would have to be physically present in the patient room to be in control of the medication.

This is another standard that ACEP has questioned and continues to discuss with the Joint Commission.

Question: Does ACEP provide input to the Joint Commission regarding their standards? 

Through the appointment of a representative and an alternate representative to the Hospital Professional Technical Advisory Committee (PTAC) and the Ambulatory PTAC ACEP has had a voice in the development and implementation of standards. This has allowed ACEP through its representatives to have input on virtually every current and proposed Joint Commission standard.

The process for review of standards typically results in materials being sent to the PTAC representative and the Dallas office for initial review. The Emergency Medicine Practice Department staff reviews the proposed standards or changes to the standards and submits salient pieces that are germane to emergency medicine to the Emergency Medicine Practice Committee and/or other committees for review and comment. Comments are reviewed and approved by the ACEP president prior to submission to the Joint Commission. These comments are then shared with ACEP's PTAC representative prior to the PTAC face-to-face meeting. When ACEP responds to Joint Commission requests for comment, the responses are posted on the ACEP web site under Practice Resources.

Staff is available to provide background materials or information to the PTAC representative prior to the meetings or phone conferences.

ACEP staff continue to have interaction with the Joint Commission and frequently pose questions to the Joint Commission Standards Interpretation Department on behalf of College members. Recently, staff have addressed questions on standards relating to medication management, restraints, patient safety, certification of stroke centers and sedation.

Question: What is ACEP's position on the Joing Commission certification of stroke centers? 

In early February 2004, the Joint Commission officially rolled out its certification program designating qualifying hospitals as "primary stroke centers."

There are several reasons why certifying hospitals as stroke centers is controversial. One is the use of t-PA, whose effectiveness in the treatment of acute stroke continues to be met with skepticism by some physicians. The ACEP policy statement on t-PA approved in 2002 says, "There is insufficient evidence at this time to endorse the use of IV t-PA in clinical practice when systems are not in place to ensure that the inclusion/exclusion criteria established by the NINDS guidelines for tPA use in acute stroke are followed." The Society for Academic Emergency Medicine position statement on acute stroke released in 2003 states, "Currently insufficient data exist to mandate thrombolytic therapy as the standard of care for acute ischemic stroke for all patients across all medical treatment settings."

There is also significant concern that designated stroke centers will lead to redistribution of patient volumes in major urban areas and contribute to overcrowding, potentially leading to adverse outcomes for patients in need of other time dependent conditions. The Society of Academic Emergency Medicine (SAEM) position states, "Although advocacy of stroke centers is well-intended, it is premature to stratify acute care hospitals. Such hierarchical stratification should await outcomes data demonstrating the overall systems benefit of such centers."
Another concern surrounding stroke center designation is the impact on emergency medical services. It remains unclear how EMS will handle issues regarding diversion and whether designated stroke centers will have a legal obligation to accept acute stroke patients even when there is no space to receive them. It would be preferable to proactively sort this issue out rather than leave it the legal community to do it at the expense of the EMS director.

Question: What is the difference between Joint Commission certification and accreditation? 

Accreditation is a distinction given to a health care organization when it is determined that the organization meets or exceeds the Joint Commission's standards and quality expectations. Hospital accreditation is the determination that an organization is in compliance with the applicable Joint Commission standards.

In addition to accreditation the Joint Commission has a number of voluntary certification programs. The Disease-Specific Care (DSC) programs include certification for asthma, heart failure, stroke, and chronic kidney disease. These programs evaluate disease management and chronic care services that are provided by health plans, disease management service companies, hospitals, and in other care delivery settings. The evaluation and resulting certification decision is based on an assessment of:

  1. Compliance with consensus-based national standards. 
  2. Effective use of established clinical practice guidelines to manage and optimize care. 
  3. An organized approach to performance measurement and improvement activities

Other Joint Commission certification programs include Primary Stroke Center Certification, Left Ventricular Assist Device Certification, Lung Volume Reduction Surgery Certification, and Health Care Staffing Services Certification

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