Healthcare Own Goals Vol. 2: The Joint Commission

Gold Seal or Golden Theater?

Jul 08, 2025

A series on how well-intentioned decisions in medicine backfired — and what we can learn from them.

Prologue: Engines On

September 2015 — Regulators discover that Volkswagen’s vaunted “Clean Diesel” fleet is only “clean” when it knows it’s being watched. “Defeat devices” embedded in engine control software could detect when a car was undergoing official emissions testing and temporarily reduce nitrogen oxide (NOx) emissions. Ingenious, but not entirely legal.

Under real-world driving conditions, the software turned off. The falsely certified cars now emitted up to 40 × the legal limit of NOx, a toxic pollutant. With help from a third-party evaluator, the EPA eventually caught on. The scandal involved 11 million vehicles and resulted in $30 billion in fines. A year later, Volkswagen’s stock price was down 30% and sales had declined 25%. Thus, Dieselgate entered the lexicon — a textbook case of false metrics, teaching to the test, and over-indexing on performative quality and safety assessments. The episode and its aftermath became an automotive industry “Own Goal” for the history books.

Three thousand miles away from Volkswagen's headquarters, American hospitals engage in their own version of regulatory theater: Joint Commission Surveys. These exercises in certification futility take place every three years and have taken on a life of their own.

Patient falls. Code blues. Intra-op blood vessel injuries. They all put hospital staff on high alert, scrambling to control the situation and avert disaster. But few things in healthcare match the sheer panic caused by an impending Joint Commission visit. Staff scurries to hide contraband coffee cups, charts get last-minute documentation polish, and long broken equipment finally gets fixed (or mysteriously disappears).

Once inspectors leave, everyone exhales, and life returns to normal. Nurses, doctors, and other frontline workers go back to relying on judgment and experience to care for patients. No draconian policies, procedures, and protocols necessary.

Hospitals treat Joint Commission site visits like a visit from the Pope, but why all the angst? Is the coveted, Gold Seal of approval worth all the commotion? Or is The Joint Commission healthcare’s version of Dieselgate — a false badge of quality hidden under a layer of manufactured results?

The second installment of our Healthcare “Own Goals” Special Series discusses the nation’s most famous accreditor: The Joint Commission.

(The Joint Commission will forever be known as “Jay-Co” in many clinicians’ nightmares — a call back to its former name, The Joint Commission on Accreditation of Healthcare Organizations, or JCAHO).

In the Beginning

The Joint Commission’s roots began with healthcare maverick Ernest Codman. Codman had the audacity to challenge the medical establishment’s culture of secrecy and general disinterest in patient outcomes. He developed “End-Result Cards” to track outcomes and complications, published his data, and invited peer review. Codman championed the notion that hospitals and doctors should be judged on whether patients actually got better — a surprisingly controversial notion for the time.

Colleagues weren’t big fans of Codman’s ideas. He eventually lost hospital privileges and was pushed out of Massachusetts General Hospital. Not one to be deterred, Codman founded his “End Result Hospital” in 1911 and continued championing performance measurement and healthcare quality. He later helped establish the American College of Surgeons and its Hospital Standardization Program — the foundation of what would become The Joint Commission (TJC). Originally called the Joint Commission on Accreditation of Hospitals, the organization launched in 1951.

In its first 14 years, Joint Commission accreditation carried limited official weight. TJC’s main goal was to set a consensus of standards such that hospitals could avoid multiple overlapping state inspections.

Everything changed in 1965 when Medicare granted TJC “deeming authority,” allowing accreditation to satisfy Medicare Conditions of Participation rules. This modest change fundamentally altered TJC’s incentives, transforming accreditation from Codman's vision of outcome-focused quality improvement into a perfunctory exercise ensuring the flow of federal dollars.

Today, The Joint Commission is an independent, not-for-profit organization that accredits more than 20,000 US healthcare programs and organizations and around 80% of the nation’s hospitals. TJC’s stated mission is to “continuously improve health care for the public…by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” Earning TJC accreditation is a significant source of pride, and qualifying facilities prominently display the National Quality Seal of Approval, otherwise known as the “Gold Seal.”

Joint Commissions Gold Seal Of Approval at Monte Stock blog — The coveted “Gold Seal”

But is TJC fulfilling the lofty goals that come with its coveted Gold Seal? Or has it succumbed to the bureaucracy, bloat, and mission creep that plagues so many regulatory agencies? While a visit from The Joint Commission still sends hospitals into a panic, does TJC still reflect what Codman intended?

Accreditation ≠ Outcomes

Oversight and independent verification of quality, safety, and evidence-based practices are good and necessary. The TJC Gold Seal of Approval, so proudly displayed, offers reassurance that a facility meets or exceeds national standards. In truth, the return on that badge of honor is murky. For all its pomp and circumstance, Joint Commission accreditation may not carry as much weight as it seems.

What the Data Shows

The assumption that accreditation = outcomes doesn’t stand up to scrutiny. A major 2018 study published in BMJ put this belief to the test, comparing 4400 hospitals across the United States, of which 2874 were accredited by TJC and 1063 underwent state-based review.

The findings:

No statistically significant difference in 30-day mortality rates between TJC and state reviewed hospitals.
A slightly lower readmission rate (0.8%) for 15 medical conditions at accredited hospitals.
No difference in readmission rates for surgical conditions.
No difference in 30-day mortality or readmission rates or patient experience. scores between TJC-accredited hospitals and those accredited by other agencies.
Slightly higher patient experience scores at state survey hospitals (3.4 v. 3.2 stars).

The authors' conclusion was damning: patients choosing a Joint Commission-accredited hospital gained no meaningful healthcare benefits over other accredited facilities. The only advantage? A modest 0.8% reduction in readmissions for medical conditions.

Permanently Sealed

Initial accreditation may take some effort, but once a Gold Seal is awarded, it’s almost never revoked. A 2018 Wall Street Journal expose found that fewer than 1% of “immediate-jeopardy” citations result in a loss of accreditation. The same investigation found that hundreds of hospitals with federal safety violations kept their Seal. If losing a Seal is almost impossible, its status as a symbol of quality and safety diminishes significantly. Why are Seals so rarely revoked? Explanations include concerning conflicts of interest and skewed financial incentives.

The fox may be guarding the hen house.

In 2017, 20 of The Joint Commission’s 32 board members had relationships with the same health systems they were supposed to oversee. Meanwhile, TJC charges hospitals for accreditation while simultaneously selling them consulting services to pass that same accreditation. As a non-profit, TJC generated over $200M in revenue, held $380M in total assets, and paid its CEO $2M in 2023. While none of this is inherently unethical, it raises concerns about potential biases and skewed incentives.

Mission Drift

Meeting The Joint Commission’s standards has become increasingly convoluted and costly. What used to be a manageable set of clinical standards has ballooned into thousands of line-items (policy-wording, fridge temperatures, eyewash-station logs) meant to perpetuate the deeming deal, not improve end-results. The surveying process costs a modest $10-45k, but hospitals may spend six figures on mock surveys, readiness consultants, and site visit prep. Thankfully, some reform is happening.

Perhaps sensing mission drift, CMS quietly ended TJC’s automatic Medicare pass in 2010. Realizing the financial and resource burden caused by the accreditation process, The Joint Commission has overhauled its process twice in the last few years. In 2023, it cut 14% of its requirements and froze fees. In the most significant redesign since 1965, TJC recently announced “Accreditation 360: The New Standard.” The program cuts the number of standards by 50% — from 1551 to 774.

These changes are welcome, but more complexity may be on the way. TJC and the National Quality Forum are piloting new certification models for four “high impact” areas: maternity care and hip, knee, spine, and cardiovascular procedures. Coincidentally, these areas mirror those commonly found in CMS VBC models like CJR, BPCI, and the upcoming TEAMs model.

Despite its ubiquity, the ROI on Joint Commission accreditation remains cloudy. Conflict of interest issues abound. Studies touting the superiority of TJC accredited hospitals are often authored by the Joint Commission itself. Ultimately, the coveted Gold Seal may be healthcare’s version of a “defeat device” — a false sense of security created by teaching to the test, not producing practical real-world results.

The Seal also comes with a hidden cost: stress and panic on the frontlines.

Panic at the Healthcare Disco

If its practical ROI is murky, the angst caused by an impending Joint Commission site visit is very real. “Joint Commission theater” plays out every few years in around 80 % of U.S. hospitals. I’ve experienced many such surveys (and mock surveys) myself. As a resident, one of my attendings would hand out a “Joint Commission Cheat Sheet” card of answers to commonly asked questions. My strategy was to hug the walls and walk the other way from anyone holding a clipboard.

Golden Theater

In the months leading up to a site visit, hospital leadership goes on alert and hushed whispers of “Jay-Co’s coming” are heard in the hallways. Overburdened healthcare workers mentally prepare for a few days of annoying workflow disruption. Site visits can be highly stressful for caregivers — so much so that the Cleveland Clinic developed an entire Joint Commission preparation program. The process is a classic example of TJC prep absurdity:

Multiple “leadership” rounds during day and night shifts
A list of 21 “gap areas” created from a consulting firm mock survey
An hour and a half spent on daily briefings and debriefings

The burden of a Joint Commission survey is undeniable. One study linked the accreditation process to increased symptoms of depression and anxiety, strained interpersonal relationships, and decreased job satisfaction. The increased stress might be justified if tied to demonstrably safer care. But, as I’ve seen firsthand, hospitals employ the same tricks Volkswagen coded into its software — be on your best behavior when being watched.

Although site visits are unannounced, the survey window is predictable, giving facilities time to enter “saint mode.” There’s ample time to declutter halls, refresh labels, and tidy care logs. Staff capitulates and promises to be on its best behavior. The Joint Commission arrives, surveys, shares findings, and disappears for 3 years.

Survey Says

In my experience, site visit outcomes are almost always the same: a favorable report that flags a few minor, correctable issues. Hospitals enact minor fixes, but broader data suggests enforcement is rare. Again, TJC rarely revokes its Gold Seal. After years of complaints, multiple serious violations, and a restraining order against its CEO, TJC finally issued a rare accreditation denial to Maryland’s Clifton T. Perkins Hospital Center, a maximum security psychiatric facility. Even then, the denial is only preliminary, highlighting how difficult it is to lose the supposedly prestigious Gold Seal.

The net effect is compliance theater, hours spent rehearsing extinguisher locations rather than addressing the problems actually driving poor outcomes and unsafe care — staff turnover and attrition, burnout, and death by 1,000 policies and procedures. While hospital care has gotten safer in the TJC era, it’s difficult to parse how much credit belongs with The Joint Commission.

If TJC disappeared tomorrow, would patients be worse off? Multiple safeguards already reinforce outcome-linked practices and safety standards. Meanwhile, we’ve turned the accreditation process into a stressful, expensive, disruptive process plagued by conflicts of interest and dubious benefits — a classic Healthcare “Own Goal.”

Epilogue: Emissions & Accreditations

Volkswagen’s diesel engines have their advantages — improved fuel economy, better durability, and lower emissions compared with other gasoline engines. Likewise, The Joint Commission has advanced real safety gains:

The Sentinel‑Event Policy (1998) forced hospitals to disclose catastrophic errors, perform root‑cause analyses, and share lessons. A language of transparency took hold years before state “never‑event” lists or federal penalties.
The Universal Protocol (2003) cemented “time‑out” rituals into every OR in America; wrong‑site surgery rates have since fallen to roughly one case per 100,000 procedures.
National Patient Safety Goals have accelerated the adoption of checklists, reducing catheter-associated infections by more than 40 percent in the 2010s.

These initiatives prove The Joint Commission can achieve results that would make Codman proud — when it focuses on actual outcomes rather than compliance theater. To be more effective, TJC should continue simplification efforts and shift focus on measuring outcomes rather than staging performative site visits. Of course, that assumes the existing accreditation process is even necessary and still makes sense.

Volkswagen’s engines needed a fancy software workaround to produce stellar results. Ultimately, they didn’t hold up to real-world conditions. Dieselgate reminds us that, although checks and balances are critical, any system reliant on staged inspections is ripe for gaming.

Put differently: oversight is essential, but stress theater and spurious metrics are not. Accreditation should be the by‑product of actually safer care, not a pageant of binder checks, hidden beverage containers, and checkboxes. When the ritual becomes self‑perpetuating and perfunctory and process supersedes outcomes, the Gold Seal carries as much weight as a doctored engine emissions report.

Thanks for reading this edition of The Healthcare Own Goals Special Series. Future articles will tackle issues such as regressive regulations, reimbursement inequalities, and other examples of good intentions gone bad. Be sure to check out our first edition tackling the absurdity of EHRs. In the meantime, we’d love to hear reader examples of other healthcare “own goals” to add to our list!