Over the next couple of months, several Joint Commission programs, standards, and updates will go into effect. Here is a brief overview of some of the bigger changes and the months they’ll go into effect.
• Elimination of Plans for Improvement (PFI)—After August 1, all PFIs will be replaced by Requirements for Improvement (RFI) issued by the surveyor.
• Updated diagnostic imaging standards—The accreditor published a checklist to help healthcare organizations prepare for new standards.
• 2012 Life Safety Code® (LSC)—CMS and The Joint Commission will begin surveying hospitals on the 2012 LSC on November 1. HFAP has published itsprepublication standards for LSC surveys as well.
• Antibiotic stewardship programs (ASP)—On January 1, ASPs will be mandatory in CMS- and Joint Commission-accredited facilities.
• Survey Analysis for Evaluating Risk (SAFER) matrix—As of January 1, the SAFER matrix will replace the current Category A and C scoring methodology.
• Catheter-associated urinary tract infections (CAUTI) National Patient Safety Goal (NPSG)—On January 1, The Joint Commission’s newest NPSG will go into effect, with facilities expected to drastically cut the rate of CAUTIs.
• Updated Integrated Care (ICC) program standards—Effective as of January 1 for Joint Commission-accredited facilities
• Updated advanced heart failure certification—Effective as of January 7 for Joint Commission-accredited facilities
The Joint Commission has set up a program for healthcare organizations that receive Preliminary Denial of Accreditation (PDA) decision PDA02. The decision is rendered when a facility has serious and widespread noncompliance issues. The accreditor says the new policies are to help organizations with a PDA02 improve themselves and get back up to standard.
The changes include:
- Organizations must submit an acceptable Evidence of Standards Compliance (ESC) within 30 days and address the Requirements for Improvement (RFI) identified as the drivers of the PDA decision.
- Upon approval of the ESC, the accreditor will conduct an on-site ESC survey.
- If Condition-level findings are identified, a Medicare Deficiency Survey must be conducted within 45 days. The organization will have the option of combining this survey with the on-site ESC survey.
- If the organization has a successful on-site ESC survey, the accreditation decision will change from PDA to Accreditation with Follow-up Survey (AFS).
- Areas of risk and available Joint Commission resources will be reviewed in a conference call with leadership from The Joint Commission and the organization.
- The organization’s leadership must participate in the Intracycle Monitoring (ICM) process, which occurs at 12 and 24 months.
- The organization’s next triennial survey will occur in the earlier segment of the 18-to-33–month window.
- If the organization’s next triennial survey results in a repeat PDA decision, the organization will receive a recommendation for Denial of Accreditation (DA) with the opportunity of an expedited appeal.
In mid-April, The Joint Commission updated its Leading Practice Library (LPL) to a more user-friendly interface. The LPL is full of real-life solutions to healthcare problems, all of which have been reviewed and approved by The Joint Commission. Users can browse the LPL by specific topics and all the documents are cross-referenced with Joint Commission manuals.
The changes include:
- More refined search options including program, chapter, location, and organization size.
- The ability to create your own personal library of “favorited” practices and documents.
- A faster, simpler, and less technical submission process.
- New help guides in both written and video formats.
The LPL is available to Joint Commission accredited or certified organizations for free on their secure extranet.
The Joint Commission announced plans to delete 131 standards and Elements of Performance from its hospital program requirements. The accreditor released a prepublication list of all the requirements, along with the rationale behind deleting each one. The deletions go into effect on July 1, 2016 and are part of an effort to improve the accreditation process.