JCAHO Requirements for Hospitals


The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) was developed in 1951 to set standards for hospitals and other facilities where patients are treated. The 2 main goals of JCAHO are to increase the quality of care for patients and to ensure patients rights. Hospitals must meet certain standards set forth by the commission to become accredited. These standards are detailed in The Comprehensive Accreditation Manual for Hospitals (CAMH).


In 2003, JCAHO set forth National Safety Patient Goals (NPSG). To provide a safe environment for patients, JCAHO-accredited hospitals must ensure that their staff members are properly trained and competent to perform the services for which they were hired. Understaffing and lack of security can put a patient's safety at risk. All staff should wear a hospital badge with a color photo for easy identification. Also, an annual risk assessment is required of the physical environment to identify unsafe conditions.

Patient Identifiers

At least 2 patient identifiers must appear on a blood sample or other specimen taken from the patient. Examples of patient identifiers are name, Social Security number or telephone number. These identifiers must also appear on a patient's wristband and any drug that is being administered to the patient to prevent mix-ups. Administering the wrong medication to a patient can lead to severe consequences, including death.


Accredited hospitals are subject to comprehensive surveys. Surveys take about 3 days and cost the hospital thousands of dollars to conduct. Hospitals were once provided with ample notice, usually months, before these on-site inspections. This allowed the hospital to get everything in order, especially medical records, and prepare their staff for the inspection. But this has since changed; inspections are now unannounced and can occur at any time between the 18th and 39th month of the last accreditation.


Hospitals with JCAHO accreditation also meet the requirements set forth by the Center for Medicare and Medicaid Services (CMS). Therefore, these hospitals are able to gain reimbursement for services rendered to Medicare and Medicaid patients. JCAHO can also issue citations to hospitals that are found to be in violation of a JCAHO requirement. If the issues cited are not rectified within a specified amount of time, JCAHO can revoke the hospital's accreditation.

Patient Complaints

JCAHO requires that accredited hospitals provide patients with the opportunity to file a complaint regarding the treatment received at the hospital. The hospital must acknowledge receipt of the complaint and follow up with the patient for additional information. Medical complaints concerning the quality of care received must be reviewed by the hospital's quality risk department.

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