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UC Davis Health System

UC Davis Health System

Accreditation

UC Davis Medical Center is accredited by the nation's oldest and largest hospital health standards-setting organization. 


What accreditation is

UC Davis Medical Center is accredited by The Joint Commission, an independent not-for-profit organization dedicated to raising the level of safety and quality of health care. Accreditation is considered a symbol of quality in the health-care industry, and the Joint Commission is considered the nation’s predominant health standards-setting body. 

Joint Commission Gold Seal logo
The Joint Commission Gold Seal logo for accredited hospitals.

The Joint Commission's 32-member governing board includes physicians, administrators, nurses, employers, labor, health plan leaders, quality experts, ethicists, a consumer advocate and educators.

Accreditation is essentially an inventory of operational systems and procedures that the Joint Commission believes are critical to the safety and quality of patient care at a hospital. Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment. The organization develops its standards in consultation with health care experts, providers and researchers, as well as measurement experts, purchasers and consumers.

According to the Joint Commission Web site, "Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards."

Accreditation is voluntary, and supplements mandatory government licensure and certification. 

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How it works

The Joint Commission uses a wide range of standards for hospital accreditation, from infection control to emergency preparedness.

The Joint Commission uses a wide range of standards for hospital accreditation concerning a wide variety of topics, such as:

  • Educating patients and upholding patient rights
  • Controlling infections
  • Managing medications
  • Preventing medical errors
  • Verifying staff qualifications and competency
  • Emergency preparation, and
  • Collecting performance data and using it to drive improvements.

The commission issues a customized list of standards and systems for hospital staff to check their operations against. Hospitals submit reports to the commission for review and consideration, and undergo on-site surveys and inspections that may last a week. 

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How it's enforced

More on accreditation

The Joint Commission 

National Patient Safety Goals for hospitals 

National Patient Safety goals for home care 

Speak Up safety campaign 

To maintain accreditation, UC Davis Medical Center must also:

  • Perform intracycle monitoring with action plans to address any compliance issues.
  • Submit data every three months about how it treats certain conditions, such as heart attack and pneumonia.
  • Submit to unannounced on-site surveys a minimum of once every three years. During an accreditation survey, The Joint Commission evaluates an organization’s performance of functions and processes aimed at continuously improving patient outcomes. For instance, surveyors select patients based on established clinical service groups and conduct patient/unit tracers to review the services patients received.  Surveyors also use on-site observations and interviews and review documents and information requested to evaluate compliance.

Based on survey findings hospitals are Accredited, Accredited with Follow-up Survey, Contingent Accreditation, Preliminary Denial of Accreditation, Denial of Accreditation. UC Davis Medical Center received Accreditation following the last full survey.

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How to report problems or concerns

Everyone has a role in making health care safe. That includes doctors, health-care executives, nurses and many health-care technicians. As a patient, you can make your care safer by being an active, involved and informed member of your health-care team. It's part of the Speak Up campaign, The Joint Commission's national initiative to maintain and increase the safety of patients by encouraging them to become actively engaged in their care. Read more about how to Speak Up 

If you have any concerns about your care or safety at UC Davis Medical Center that have not been directly addressed to your satisfaction, you are encouraged to contact medical center management through UC Davis Medical Center's Patient Relations department at 916-734-9777.

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