Key Factors by TJC for Functional and Organizational Integration

As organizations continue to expand their footprints to address patient and community needs, we are often asked about whether those new care locations or services will be or should be included in the organization’s accreditation program.  Sometimes the answer is easy as CMS sets the expectation that any care location that is billing under the parent organization’s CCN number must be part of it’s CMS Certification process, be that directly with CMS or through an accrediting agency with appropriate deemed status with CMS.  Organizations are also reminded, if they are accredited by The Joint Commission, that TJC applies both functional and organizational integration criteria to determine if a service or care location qualifies for inclusion in the accreditation.  These criteria consider items such as financial and governance structures along with considerations related to commonality of medical staff, human resources and policies/procedures from a functional perspective.  The Joint Commission publishes this criterion in an easy to access table within the Accreditation Process Chapter of their accreditation manuals.

We encourage organizations to review and apply the criteria as part of their strategic planning and growth initiatives.

Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 29 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.

Please contact us for questions or more information at  704-573-4535 or


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