TJC March 2009 New and Revised Standard Changes

Thursday, March 26, 2009 the Joint Commission released revised 2009 Release of the Revised 2009 Accreditation Requirements for the Hospital Accreditation Program. This revision is in response to the 165 new and revised elements of performance released January 5, 2009, specifically developed to further align the Joint Commission with the CMS Conditions of Participation (due to the need to accomplish the deeming authority which TJC is looking to renew in July of 2010.) In an audio-conference the week of the March 26th, TJC clarified the March  document noting a reduction to 87 new and revised elements of performance, from the January release. This new March release and reduction to 87 elements of performance does not include the category of EP (neither category A nor C are listed), and whether the EP is scored as a direct impact (level 3) or non-direct impact (level 4) EP. How these will be scored will be forthcoming with no date provided by TJC at present, but take heart, once the determination is made, there will be yet another posting of the changes, this time with the scoring categories.

 Of note in the audio-conference was a previously unannounced process whereby the Joint Commission has been assessing the heretofore revised 165 new and revised elements of performance during the hospital accreditation survey process, however, not scoring these new and revised requirements. Apparently TJC has provided through separate report, an “educational document” that is sent approximately four weeks after survey, that informs the hospital with a  picture of where the organization would fall related to the new standards, should any fail to meet compliance. The new and revised elements of performance will not impact the survey outcome and no evidence of standards compliance will be required until July 1, 2009 when scoring will commence. Effective July 1, 2009 surveyors will be scoring new elements of performance and noncompliance can impact accreditation decision and an ESC will be required. TJC noted that there may be more changes expected toward the end of the year as TJC continues to work with CMS on refining the changes within the updated requirements.

Of the 87 new elements of performance TJC stated 87 fall into two categories; “new expectations” and “other information.” 37 elements of performance fall under new expectations, with 27 of these related to restraint and seclusion and 10 relating to history and physical and preoperative and postoperative anesthesia requirements. The remaining 50 elements of performance are not new, however,   provide more specificity and are related to blood transfusion and management of infected blood.

Restraint and seclusion: TJC removed their standards under PC.03.02. 01 through PC.03.03.31, leaving PC.03.05.01 through PC.03.05.19 which mirror the restraint and seclusion requirements under the Conditions of Participation.  TJC noted this revision brought the elements of performance in line CMS’s behavioral based requirements for restraint and seclusion.

History and Physical: Requirements must be listed in the bylaws (firmly in bylaws or documents such as rules and regulations that are a component of the bylaws.) The H&P focus is the requirement for an inpatient H&P within 24 hours after inpatient admission or registration, allows for use of a previously performed H&P no greater than 30 days prior to admission or registration, requiring an update to the previously conducted H&P within 24 hours after admission or registration and prior to surgery or a procedure requiring anesthesia services, whichever comes first.

PreAnesthesia Assessment/Post Anesthesia Evaluation: Preanesthesia assessment must be performed no greater than 48 hours before anesthesia. The Postanesthesia evaluation must be performed no longer than 48 hours post anesthesia. Both must be documented.

Remaining are standards with greater specificity related to blood transfusion and handling of infected blood 40 standards.

A few more nuggets:

·       The initial requirement regarding the hospital assuming credentialing responsibilities for telemedicine providers has been removed.

·       Apparently the TJC online manual (the eDition) will not have the updates integrated until the end of the year. But…. Hospitals will be able to see a new or revised EP and “click through” to the revision deeper into the eDition (online manual.) For those hospitals without the electronic version of the standards, you get to print out the new changes and stuff them in the back of your HAP or CAMH for now.

·       Some confusion exists as to how PPRs are to be done this year (since the PPR tool will not include the new requirements until the end of the year.) TJC suggested that hospitals may want an onsite review instead of submitting the PPR. Some callers seemed upset and dissatisfied with this answer.

·       Perspectives will give a summary of the changes.

·       There will be FAQs posted as TJC and client hospitals work thorough the new changes.

We know the continued changes are frustrating and we will be reviewing the change document and providing a more in-depth analysis within the next few weeks, particularly related to the “new expectations” discussed.