In October 2006, The Joint Commission launched a Standards Improvement Initiative (SII) as part of our continuous effort to improve the standards. The goal of this initiative is to:
- Clarify standards language
- Ensure that standards are program-specific
- Delete redundant or non-essential standards
- Consolidate similar standards
As additional benefits to users, the manuals will be reorganized and the scoring and decision process will be refined.
Improvements—both format and language edits—are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs. The 2009 accreditation manuals for these programs will include the improvements from the Standards Improvement Initiative. These 2009 manuals will become available in September 2008. The 2009 manuals will be available electronically as “E-ditions” beginning in November 2008. Along with the customary free copy of the comprehensive print manual, organizations will receive a free E-dition (i.e., single user license). Beginning in 2008, feedback is being sought on standards for the behavioral health care, laboratory and long term care accreditation programs.
Feedback is critical to this initiative
This initiative includes a comprehensive engagement plan to ensure that the field has sufficient time to provide feedback. The Joint Commission will seek feedback from both accredited and non-accredited health care organizations, Joint Commission advisory groups, payers, purchasers, consumers, governmental agencies, experts, and Joint Commission surveyors. Comments and suggestions will be gathered through on-line surveys, meetings, one-on-one interviews and focus groups.
For each accreditation program The Joint Commission has engaged an Accredited Customer Group that includes representatives from the various settings and services within each program. The representatives of these organizations are listed on the SII webpage. In addition, the Joint Commission is getting advice from each accreditation program’s Professional and Technical Advisory Committee.
Why is The Joint Commission undertaking this initiative?
It is imperative that The Joint Commission continuously assess its standards to ensure their relevancy in a changing health care environment. The standards guide safety and quality of care efforts in nearly 15,000 health care organizations nationwide. Also, the standards are being used increasingly by organizations as a management aid to drive improvements in operations and quality of care.
Benefits of the Standards Improvement Initiative
- Standards, rationales and elements of performance will be easier for health care organizations to interpret and employ.
- Scoring will be simpler. Scoring of the standards and EPs will clearly support the accreditation decision. Each EP will speak to a very specific requirement.
- The decision process will more accurately reflect organizational performance related to safety and quality of care.
- Manuals will be easier to navigate.
- All EPs will be placed in relevant chapters. For example, the Performance Improvement chapter will be limited to the technology involved in collecting, analyzing and aggregating data, and the systems that an organization would use to do that work. The PI initiative itself—the evaluation and the quality and outcomes—would be merged into the most relevant chapters.
- Standards related to the medical record will be in one place in the manual.
SII Timeline
October 2006: The Standards Improvement Initiative was launched. The Joint Commission began seeking feedback through an on-line opinion survey and public comment on standards for the Phase 1 programs: ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation programs.
June 2007: “Virtual” pilot testing was conducted with selected surveyors and Central Office staff.
August and October 2007: The Surveillance, Prevention and Control of Infection; Improving Organization Performance; and Management of Information chapters were approved by the Standards and Survey Procedures Committee.
November 2007 and January 2008: The Management of Human Resources; Management of the Environment of Care; and Medication Management chapters were approved by the Standards and Survey Procedures Committee.
February 2008: The Provision of Care (first half); Ethics, Rights, and Responsibilities; and Life Safety* chapters were approved by the Standards and Survey Procedures Committee.
Early 2008: Work started on improvements for the Phase 2 programs: behavioral health care, laboratory services, and long term care accreditation programs.
April 2008: The Joint Commission began conducting mock surveys using the improved standards and manuals.
June 2008: The Provision of Care (second half); Waived Testing*; Transplant Safety*; Record of Care, Treatment and Services*; Equipment* (Home Care program only); Emergency Management*; and Nursing chapters were approved by the Standards and Survey Procedures Committee. This concludes the improvements to the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation manuals.
July 2008: Final revised standards will be provided via The Joint Commission website to accredited organizations in the affected programs.
January 2009: Improvements to the standards are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs.
*New chapters, created from current standards
For more information
Visit the SII webpage for FAQs and other information, including Update 1 which provides an overview of SII, the improved scoring and accreditation decisions, as well as sample standards that illustrate the changes being made. Questions can be sent to standardsimprovement@jointcommission.org, or contact Carol Gilhooley, director, Division of Standards and Survey Methods, at (630) 792-5270.
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