Joint Commission suddenly releases more new EPs for 2009

Hi everyone, it’s Scott Wallask.

In an about-turn from what it said throughout 2008, The Joint Commission has released a slew of new elements of performance (EPs) that were not previously in the accreditor’s 2009 standards. And how’s this: The EPs went into effect January 1, but were just released January 5. Surveyors won’t score the new EPs until July 1, 2009, though, and it’s possible further changes are coming.

And to be fair, the new requirements seem minor or things many of you are already doing.

The changes have been prompted by The Joint Commission’s application for deeming status from the Centers for Medicare & Medicaid Services (CMS). For years, The Joint Commission had automatic deeming status to survey hospitals on behalf of CMS, but CMS is now requiring the commission to reapply for this status. As a result, the accreditor has needed to update some of its requirements to more closely align with the Medicare Conditions of Participation.

When The Joint Commission originally published its revamped standards last year, it constantly indicated that no new requirements would be coming in 2009.

The following new or revised EPs will be of interest to safety officers who work in hospitals that use Joint Commission accreditation to meet CMS requirements:

• EC.02.02.01 (hazardous materials and waste), new EP 14 requires hospitals to check radiology staff members for radiation exposures using meters or badge tests, and document these activities (the hospital determines the time frames)
• EC.02.02.01, new EP 15 requires hospitals to ensure that radiology services, including ionizing procedures, are free from hazards to patients and staff members
• EC.02.04.03 (inspecting medical equipment), new EP 14 required qualified personnel to inspect, test, and calibrate nuclear medicine equipment annually, and document these activities
• EC.02.06.01 (maintaining a safe environment), revised EP 20 requires hospitals to ensure that patient areas are clean, sanitary, and free of offensive odors
• LS.01.01.01 (complying with the Life Safety Code), new EP 4 requires hospitals to maintain records of inspections and approvals by local and state fire authorities

Watch for further updates on this blog, in Briefings on Hospital Safety, and at HCPro’s 3rd Annual Hospital Safety Center Symposium May 14-15 in Las Vegas.