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The Joint Commission Clarifies Accreditation Participation Requirement

by Barbara Kram, Editor | September 18, 2007
Physicians and medical staff members who have concerns about the safety and quality of care at their hospital may report those concerns with the understanding that retaliatory disciplinary action is prohibited, according to explicit new rules announced by The Joint Commission. The accreditation participation requirement previously referred generally to hospital staff, although it has always been intended that physicians and medical staff be included as part of 'good faith participation' in the accreditation policy.

The revised requirement, which will become effective January 1, 2008, means that accredited hospitals must educate staff and medical staff that any employee or any physician who has concerns about the safety or quality of care provided in the hospital may report these concerns to The Joint Commission. Hospitals also are expected to inform staff and medical staff that no disciplinary action will be taken if concerns are shared with The Joint Commission, and hospitals should demonstrate this commitment by refraining from taking action against employees or physicians who report their concerns to The Joint Commission.

"The Joint Commission policy forbids accredited organizations from taking retaliatory actions against those who report quality of care concerns because it is the obligation of everyone in an organization to make patient well-being the priority," says William E. Jacott, MD, special advisor for professional relations with The Joint Commission.

Anyone who has concerns about the safety or quality of care at an accredited organization may share those concerns with The Joint Commission Office of Quality Monitoring by phoning (800) 994-6610, or by sending an e-mail to complaint@jointcommission.org.