Are you a Joint Commission accredited hospital? Are you aware that the Joint Commission has made several changes to their comprehensive accreditation manual for hospitals effective January 2017?
Here at PolicyMedical, we aim to keep our clients informed, so we have put together a summary of some of the major changes that have been made:
Change in Scoring Methodology
The usual scoring methodology has been replaced with a new approach referred to as the Survey Analysis for Evaluating Risk (SAFER) matrix. This matrix eliminates the Category A and C designations, Measures of Success (MOS), and direct and indirect impact Elements of Performance (EPs). It is a 3×3 color-coded matrix that is intended to enhance the visual impact of information so that organizations are better able to understand the most critical issues and set their priorities for improvement based on the severity of the risk. With this new approach, surveyors will use the matrix to assign levels of risk based on a) the likelihood that a deficiency will cause harm to patients, staff or visitors and b) how widespread the issue is within the organization – the scope of the issue.
All accreditation certification programs except for psychiatric hospitals that use Joint Commission accreditation to meet CMS deemed status requirements will begin to receive the SAFER matrix in their reports beginning January 1, 2017. Psychiatric hospitals began receiving theirs June 6, 2016.
Amendments to Applicability of Standards and Elements of Performance (EPs)
- In the Environment of Care standard, EC.02.03.05, EP 2 which deals with hospitals testing supervisory signal devices on the inventory, is now applicable to ALL
- Former EP 25 of EC.02.03.05 which states in part, “For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems …” has been updated and renumbered as EP 27 and is now applicable to ALL
- In the Provision of Care, Treatment, and Services (PC) standard, PC.01.03.03, EP 4: former Note 3 (“For hospitals that use Joint Commission accreditation for deemed status purposes: When restraint or seclusion is used in an emergency situation…”) has been renumbered and revised to include ALL
- 03.05.01 through PC.03.05.19 on Restraint and Seclusion are now applicable to ALL hospitals. The standards and EPs that were applicable to hospitals that are not deemed-status (PC.03.02.01 – PC.03.02.11 and PC.03.03.01 – PC.03.03.31) have been deleted.
New Standard and EPs
- A new standard for establishing an antimicrobial stewardship program has been added to the Medication Management chapter and to accommodate this, a section on Antimicrobial Stewardship has been added to the chapter outline. This standard, MM.09.01.01, comes with 8 EPs.
- The submission timeline for Evidence of Standards Compliance (ESC) has been moved to 60 days EXCEPT for organizations recommended for Preliminary Denial of Accreditation (PDA).
- The leadership of organizations with a PDA02 decision (a decision, based on significant and pervasive patterns of non-compliant standards) is now required to participate in the Intracycle Monitoring (ICM) process.
PolicyMedical strongly believes in communicating the interests and needs of those we serve, which leads to overall happiness and health. While this article serves as a summary of some of the changes, if you want further details on navigating through the new comprehensive accreditation manual for hospitals, contact us and our CMO would be happy to provide further clarification.
The key is not only to begin a conversation but to continue it and for hospitals to understand what solutions can improve standards of patient care. PolicyManager ™ not only ensures that every policy is up-to-date for all who are using the software, but it also provides users a seamless experience through its editing and sharing capabilities. Want to learn more? Request a free no-obligation demo.