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The Joint Commission: COVID-19 response and accreditation

By: Mark Pelletier, MS, RN

Resources and advocacy to support healthcare organizations.


  • The Joint Commission has taken actions to support health care organizations with accreditation surveys and certification reviews during the pandemic.
  • The Joint Commissions COVID-19 portal provides helpful information and resources for nurses and health care organizations on the pandemic.
  • The Joint Commission has provided advocacy for nurses and health care workers during the pandemic.

On March 13, 2020, a national emergency was declared as COVID-19 continued to spread across the United States. Three days later, The Joint Commission suspended all U.S.-based accreditation surveys and certification reviews. Joint Commission Resources, Inc. consulting engagements and the Joint Commission Center for Transforming Healthcare education events also were put on hold

Joint Commission surveys require additional time and resources from healthcare leadership and staff, especially nurses. The challenge of suddenly providing care in a pandemic with no roadmap for treatment made survey preparation impossible.

Taking action

Similar to the situation for healthcare organizations, The Joint Commission had to completely pivot. We went from surveying more than 1,000 facilities per month to launching extensive resources to help our more than 22,000 accredited organizations navigate the pandemic. We knew providers urgently needed to know everything they could about the virus, but we had to balance timely information with accuracy. A summary of our work follows.

COVID-19 Portal

To address each setting’s unique challenges, we developed a COVID-19 portal with resources based on patient population and type of services provided. The portal includes resources related to:

We add new resources to the portal as they become available.

Supporting equity in healthcare

Early research indicates that Black Americans are dying of COVID-19 at twice the expected rate of other races. In some states, they’re dying at three to four times the rate. The low testing rates in Black communities and communities of color may mean these numbers are even higher. The Joint Commission issued a statement on racial justice and equity to emphasize its refusal to tolerate racial discrimination within the organization or the healthcare organizations we accredit and certify. Based on our commitment to safe, high-quality healthcare for all, The Joint Commission reiterated the requirement that accredited healthcare organizations protect the rights of individuals and prohibit discrimination. Our patient-centered communication standards guide providers to ensure everyone receives bias-free care.

Standards interpretation support

Our Standards Interpretation Group fielded questions from healthcare organizations about maintaining staff and patient safety compliance, especially with regard to infection prevention and control requirements. We answered questions on our website and shared responses via social media and our Infection Prevention and Control blog to ensure healthcare workers everywhere have access.

Advocating for healthcare workers

As an advocate for patient and healthcare worker safety, The Joint Commission supports nurses and other providers having access to appropriate PPE. We recognize that healthcare organizations struggle to obtain sufficient supplies to protect their staff and that available PPE may come with unbudgeted and unanticipated costs. (See PPE advocacy.)

PPE advocacy

The Joint Commission took several steps to ensure healthcare organizations have the personal protective equipment (PPE) they need to protect staff and patients:

  • In collaboration with five other national medical organizations, The Joint Commission signed a Public Statement on the Shortages of Critical Medical Equipment, urging the federal government to take action to speed up production of N95 respirators, gowns, masks, and other equipment.
  • When it became clear that healthcare organizations that couldn’t provide sufficient PPE were requiring staff to go without or reuse masks and respirators for extended periods, The Joint Commission endorsed staff bringing their own masks from home.
  • The Joint Commission released a statement in support of universal masking of staff in all healthcare organizations to prevent virus spread by asymptomatic individuals.

Supporting healthcare worker mental health

A healthcare organization’s ability to respond to the stress of providing adequate care during a crisis depends on employee mental health. Systems must support institutional and individual resilience. In response to that need, The Joint Commission issued a Quick Safety alert advocating for the mental health of nurses and other providers during the pandemic. The alert addressed the real and justifiable anxiety, stress, and fear healthcare workers are experiencing. In addition, The Joint Commission (in collaboration with the National Council for Behavioral Health) offers a free webinar on trauma and resilience-oriented healing strategies, which can be viewed on-demand.

CMS 1135 waivers

The Joint Commission’s relationship with CMS has taken on increased importance as the pandemic continues. Our leadership teams confer daily about this public health emergency, including discussions on CMS 1135 waivers. Typically, these waivers have been granted only at the state level for disasters such as hurricanes and tornados. Considerable anxiety existed about what was covered in a blanket waiver, how to request the waivers, and what are the relevant dates. The Joint Commission developed webinars and blogs to explain the process.

Improved accreditation processes

During the pandemic, The Joint Commission continues to design and improve tools and streamline accreditation processes.

  • Refining bylaws approach. The Joint Commission developed a checklist for the bylaws review and an amendment to the overall process. Accredited organizations will soon have a checklist (available in the customer version of the Surveyor Activity Guide) to verify and include any bylaw changes since the last triennial survey.
  • Emergency management outreach. In addition to streamlining selected operational issues, we wanted to learn how we can support our customers during the pandemic. Outreach to organizations has allowed us to hear directly from healthcare organizations about their unique needs.
  • Accreditation process. In March, when the pandemic prevented on-site surveys, The Joint Commission began surveying organizations virtually. Our virtual solution allows healthcare organizations to upload selected documents to a secure site, where they’re reviewed by surveyors. Using videoconferencing, surveyors conduct interviews and discussions with patients and healthcare staff and manage building tours. To date, we’ve completed 458 virtual surveys, which have received positive feedback from organizations and surveyors.

The road ahead

We continue to work closely with CMS and have requested that many of the innovations developed to response to the pandemic continue after the crisis ends. We’re hopeful that maintaining these procedures will result in more efficient and creative interaction among surveyors, healthcare organizations, and patients.

The pandemic has shined a light on the shortcomings of our healthcare system. The pandemic is personal. In addition to providing patient care, nurses face the unrelenting threat of the virus to patients, families, colleagues, and themselves. The Joint Commission will continue to support healthcare organizations and frontline workers as COVID-19 continues. We will do our part to meet your needs during these extraordinary times.

Editor’s note: This is an early release, web exclusive article that will appear in the upcoming January 2021 issue of the American Nurse Journal. 

Mark Pelletier is the chief operation officer and chief nurse executive at The Joint Commission in Oakbrook Terrace, Illinois.

1 Comment. Leave new

  • Kathy Leonard
    January 10, 2021 9:21 pm

    Mark, thank you for sharing the resources that have been developed and share. Thank you for your leadership during this crisis.


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