In an effort to modernize healthcare accreditation, The Joint Commission recently introduced Accreditation 360: The New Standard—a new approach designed to elevate clinical outcomes for patients and reduce administrative burden for healthcare providers.
For surgeons, this process represents an opportunity to lead patient-centered innovation and healthcare quality and safety. Notably, this accreditation process prioritizes patients and their families and caregivers.
Why Accreditation 360 Matters to Surgeons
Surgeons operate at the intersection of high acuity, rapid decision-making, and measurable outcomes. They balance all this with the patient squarely at the center of every decision. Accreditation 360 recognizes this by shifting the focus from process-heavy compliance to outcome-based performance, enabling surgical teams to demonstrate excellence in patient care through data that reflect real-world impact.
The approach also introduces next-generation certifications—developed in partnership with the National Quality Forum—that prioritize outcome measures in four high-volume, high-impact areas: Hip and Knee Procedural Care, Spine Procedural Care, Cardiovascular Procedural Care, and Maternity Care. These certifications, all of which align with the work of surgeons, are designed with best data and guidance input from individuals and organizations that are experts in the field—clinicians, health systems, payers, and patients—ensuring they reflect the priorities of those delivering and receiving care.
Less Burden, More Relevance
One essential aspect of Accreditation 360 is that the program simplifies the accreditation process and reduces the associated burden on the healthcare worker community. The Joint Commission has eliminated more than 700 outdated or redundant requirements for hospitals and critical access hospitals, building on the 400 requirements removed in 2023.
The updated hospital accreditation manual now distinguishes standards that are aligned with the Centers for Medicare & Medicaid Services Conditions of Participation from The Joint Commission’s National Performance Goals—a new framework that consolidates safety priorities into 14 streamlined, evidence-based goals. For surgeons, this change means more time focused on delivering safe, effective, and compassionate care to patients and less time navigating redundant documentation.
The Joint Commission also is making these updated standards more accessible. In a move toward greater transparency, The Joint Commission standards are now available online and searchable for the public.
Continuous Engagement and Real-Time Support
Today, postoperative patients typically require a short stay or no stay in the hospital following a surgical procedure. Approximately 50 million surgeries are performed annually in the US, and 75% to 80% are ambulatory surgeries. Patients undergoing major surgical procedures, such as total hip or knee replacement as well as cholecystectomies and appendectomies, are frequently in the hospital overnight or sent home on the same day.
This shift means that patients’ loved ones are managing their postoperative care at home when they have little or no medical education or information. However, the public and payers expect that patient outcomes would be the same as when they were managed 24/7 in the hospital by professional physicians, nurses, therapists, nutritionists, and rehabilitation specialists.
The new Continuous Engagement option for Accreditation 360 offers ongoing support and perpetual survey readiness, replacing episodic inspections with a more collaborative, real-time approach. The focus is not on “ramping up” for a Joint Commission survey, but being perpetually ready to meet every patient’s healthcare needs by providing consistently high-quality, safe, and compassionate care.
It moves the survey process to one of collegial partnerships to improve performance. This approach is especially relevant for surgical departments, where continuous quality improvement and rapid-cycle feedback are essential to maintaining excellence and elevating patient care. It will generate support and guidance from The Joint Commission, as needed or desired.
Data-Driven Insights and Shared Learning
The Accreditation 360 process is underpinned by advanced data and analytics and benchmarking tools that allow healthcare organizations to compare performance, identify gaps, and adopt high-performing practices from peers across the country. The new SAFEST (Survey Analysis For Evaluating STrengths) program will evolve into a national database of leading practices, enabling healthcare organizations to learn from high-performing institutions and contribute their own innovations.
The Joint Commission surveyors will be looking for what healthcare organizations are doing well (not just where they are struggling) and sharing those leading practices. When data-based on “trusted” information is shared, patients and their caregivers benefit.
A Message to the Surgical Community
As Jonathan B. Perlin, MD, PhD, MSHA, MACP, president and CEO of The Joint Commission, stated, “Reducing burden helps busy clinicians and healthcare organizations focus on what matters most: delivering the safest, highest-quality, and most compassionate healthcare possible.”
This is a message that resonates deeply with the surgical community. Surgeons are uniquely positioned to lead the charge in outcome-driven, patient-centered care. Accreditation 360 empowers them to do just that.
Looking Ahead
The Joint Commission is actively engaging with healthcare leaders, including the ACS, to ensure Accreditation 360 reflects the needs and insights of the surgical profession. Future issues of this column will provide updates on the innovations from Accreditation 360.
For more information, visit: www.jointcommission.org/what-we-offer/accreditation/accreditation-360.
Disclaimer
The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the ACS.
Dr. Lenworth Jacobs Jr. is a professor of surgery at the University of Connecticut in Farmington and director of the Trauma Institute at Hartford Hospital in Connecticut.
