Achieving Joint Commission Accreditation: Tips from a Former TJC Employee

Sierra Peritore, Licensing & Accreditation Manager
February 9, 2023 by
Simplifyance, Gina Thorne

If you work in healthcare, you are probably familiar with the necessary expectation of accreditation.  JCAHO, now referred to as TJC, has earned a bad rap over the years, yet we all know how important TJC’s Gold Seal of Approval is in demonstrating the highest quality of healthcare.  As a former TJC Senior Account Executive on the Behavioral Healthcare team and currently the Licensing & Accreditation Manager specializing in TJC behavioral healthcare consulting, I’m here to tell you that the accreditation process is not as scary as it may seem! 

Keep reading, as I share my tips for achieving (and maintaining) behavioral health accreditation, from a former TJC employee.

Tip #1: Utilize TJC’s Free Resources

The most challenging part of any project is figuring out where to start.  While the accreditation process can feel overwhelming, it is important to be aware of the resources that are available to you, and where to access them. The TJC website has an Accreditation Guide available and is a great place to start. The Accreditation Guide covers the benefits of accreditation, eligibility, pricing, accreditation standards, and how to apply. You can also request a free 90-day trial of the Behavioral Health Care and Human Services standards manual. Reading and understanding TJC’s standards is essential in evaluating your program’s accreditation readiness.

Tip #2: Delegate

When it’s time for your initial survey, keep in mind that TJC is going to evaluate your entire program, from clinical and medical, to Human Resources, to life safety and environment of care. The survey is broken into sessions to address each of these departments.  As a leader, it is important to allow your department leads to interact with the surveyor and serve as subject matter experts.  Fight the urge to be in control of the entire survey. Delegate sessions and allow your department leads to “show off” the good work they do within their department every day.

Tip #3: Use the Survey as an Educational Experience

During the survey, it may feel like the surveyor is putting your organization in the “hot seat” by peppering questions about your program.  While this may feel stressful,  remember the accreditation process is designed to improve your program and enable you to provide the highest quality of care. 

Of course, it is important to answer the surveyor’s questions and have meaningful conversations, but the survey is also the perfect time to ask questions of the surveyor! Ask for their recommendations and inquire about best practices. Remember, these surveyors travel the country and see hundreds of programs. Tap into your surveyor as a resource and use the entire survey process as an educational experience.

Tip #4: Maintain Accreditation Using Simplifyance™

Achieving TJC accreditation is an incredible accomplishment, however, it is just the beginning of your accreditation journey. Once accredited, TJC surveys your program every three (3) years to ensure you maintained compliance with their standards.  In some ways, the re-accreditation surveys are more challenging, as the surveyor will ask for documentation and proof that you’ve been compliant with the standards for the last three (3) years. 

So, how do I recommend your organization maintain compliance? Consider Simplifyance™ as a partner utilizing an innovative compliance software solution that automates accreditation tasks, data collection and aggregation, and report production. The software manages your compliance tasks in an organized repository to easily present to the surveyor during every TJC accreditation survey. 

While achieving and maintaining TJC accreditation is not easy, it is not impossible. Your clients deserve the highest quality of behavioral healthcare, and the tips above will help to ensure that is what they receive!


Sierra is a passionate professional specializing in compliance and operations for behavioral healthcare organizations. Sierra is the Licensing and Accreditation Manager at Simplifyance™, where she supports healthcare organizations in obtaining or maintaining accreditation, certification, and/or state licensure. She began her healthcare career at The Joint Commission where she worked as a Sr. Account Executive supporting behavioral healthcare organizations providing all levels of care. Sierra feels most energized helping organizations succeed in their licensing and accreditation surveys not only to check a box, but to achieve continued dedication to improved patient outcomes, high-quality care, detailed policies and procedures, and an overall culture of excellence. Sierra is Yellow Belt certified in Robust Process Improvement (RPI). She is a proud Arizonian and spends her free time with family and traveling.