The Joint Commission Accreditation Committee at its April 17, 2008 meeting listened to information from Joint Commission staff regarding 15 Elements of Performance in the Emergency Management standards for hospitals, critical access hospitals, and long term care organizations. Specific concerns have been identified by several user groups, individual letters and internal review by Standards Interpretation Group staff that indicated that organizations may need additional time to comply with the following Elements of Performance:
EC.4.11 EP .9 & .10
EC.4.12 EP .6
EC.4.13 EP .7
EC.4.14 EP .8 & .10
EC.4.15 EP .2, .3 & .5
EC.4.16 EP .2 & .3
EC.4.17 EP .4
EC.4.18 EP .4, .5 & .6
The action of the Accreditation Committee affected only those Elements of Performance (EP) listed above and includes the following expectation:
- These EPs are expected to be fully compliant as soon as possible, but no later than 12/31/2008
- During survey activities any of these EPs not compliant at time of survey will be cited in the survey report
a. These EPs will not contribute to the total count that aggregates toward a decision of Conditional or Preliminary Denial of Accreditation
i. There is no such thing as “capping of the Elements of Performance” in Survey Process
b. Evidence of Standard Compliance (ESC) within 45 days will be required
i. The ESC could include action plans defining the strategy to comply with these EPs by the end of 2008
All remaining Standards and Elements of Performance are required to be compliant as of 1/1/2008. EC.4.20 (Exercise Standards) must be compliant by 12/31/2008 or before.
If you have any further questions please contact the Standards Interpretation Group at 630 792 5900 or by web submittal at the Joint Commission Home Page under Standards - Online Question Form.