On August 1, The Joint Commission’s Board of Commissioners unanimously approved a resolution for The Joint Commission to apply to the Centers for Medicare & Medicaid Services (CMS) to continue its hospital deeming authority. The Joint Commission fully expects that it will be successful and, without interruption, will remain as the nation’s leading hospital accrediting body. This resolution follows the recently enacted Medicare Improvements for Patients and Providers Act of 2008, which requires all hospital accrediting bodies to complete a formal application process for their accredited hospitals to be deemed to meet Medicare requirements. Importantly, The Joint Commission’s current deeming authority for hospitals remains unaffected through the 24-month transition period described below.
Since 1965, The Joint Commission has uniquely derived its hospital deeming authority directly from the Medicare statutes. In contrast, all other accrediting bodies and all other Joint Commission non-hospital programs have always been required to submit an application to the Medicare program for its review and determination of comparability with Medicare’s regulatory requirements. Over the next two years, The Joint Commission will prepare and submit its application for hospital deeming authority to CMS and fully expects to receive a positive decision from CMS for its continuation of its Medicare recognition under the regulatory process. Hospitals should also note that the law provides for a transition period in order to minimize any potential disruption to our accredited hospitals. Specifically, any Joint Commission hospital accreditation award – and corresponding Medicare deemed status – granted prior to July 15, 2010, will remain in effect for the full term of that hospital’s accreditation. For example, a hospital receiving an accreditation award in May 2010 will continue to enjoy deemed status for the duration of its three-year accreditation period ending May 2013, subject to current Joint Commission policies and procedures.
The Joint Commission staff is working with CMS to understand its expectations, timetable and process for accepting a hospital deemed status application from The Joint Commission, and to ensure a seamless transition under the new law. To date, CMS has informed The Joint Commission that it will conduct a traditional deeming application review, where issues will be identified and resolved during the process. The review will include an assessment of a crosswalk between the Medicare Hospital Conditions of Participation (CoPs) and The Joint Commission hospital standards, and will include an evaluation of our survey processes and surveyor training programs, among other things. Look for updates on the application process in future issues of This Month. (Margaret VanAmringe, mvanamringe@jointcommission.org)
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At its August 1-2 meeting, The Joint Commission’s Board of Commissioners was provided with an update on the efforts of the MS.1.20 Task Force, formed in January 2008. The Task Force is making progress in moving toward consensus on a recommended set of proposed changes to Standard MS.1.20 related to Medical Staff bylaws. Consensus means that each member of the Task Force can agree to implement and actively support the recommendations. If the Task Force can reach consensus, the recommended changes would be the subject of a field review and consideration by the Board of Commissioners. At its June 2007 meeting, the Board of Commissioners approved revisions to the hospital standard MS.1.20 related to medical staff bylaws and associated rules and regulations and policies. Following concerns received from hospitals, the 19-member Task Force was convened in January 2008 by the Board to analyze the potential impact of implementing the revised standard. One aspect of the revised standard the Task Force was asked to examine is the perceived prescriptiveness of the standard regarding the level of associated details related to the requirements that must be in the medical staff bylaws. The Task Force will consider whether these associated details should be in the medical staff bylaws or can reside in rules and regulations or policies.
At its May 2008 meeting, the Board suspended the July 2009 implementation of the June 2007 revisions. The Standard MS.1.20 in the 2008 Hospital Accreditation Manual will remain in effect until further notice. Note: There is an indefinite moratorium on the implementation of Element of Performance 19 of the current MS.1.20. Therefore, the Joint Commission survey assesses whether each of the topics identified in EPs 1 through 18 are addressed in the bylaws, and whether necessary detail is addressed in either the bylaws, or rules and regulations, or policies. The survey does not assess how much of the detail is placed in rules and regulations or policies, rather than in bylaws; that decision is left to each medical staff and governing body. (Chuck Mowll, cmowll@jointcommission.org)
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The Joint Commission wants to know your opinion about its Speak Up patient safety program. Since its launch in 2002, the program has grown to include 10 campaign brochures and four posters, as well as Spanish language versions of all brochures. Please take a few moments to take the short survey, which has a maximum of 18 questions. The survey is open through Monday, September 29. For more information about Speak Up, visit the website. (Contact: Cathy Barry-Ipema, cipema@jointcommission.org)
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The American Case Management Association announced the availability of the 2009 Franklin Award of Distinction application. This national award of excellence recognizes those practices demonstrating commitment to collaboration, care coordination along the continuum, and the application of interdependency across disciplines in achieving patient outcomes. The Franklin Award of Distinction has been awarded annually since 2003 by ACMA and The Joint Commission. Just as this award is designed to promote the advancement of hospital case management practice on a national level, the application process is an excellent way to promote the advancement and recognition of case management within an organization. The application is due by November 28, 2008. Questions should be e-mailed to franklinaward@acmaweb.org. The application and information about the award are available at http://www.acmaweb.org/section.asp?sID=20. (Contact: Laure Dudley, ldudley@jointcommission.org)
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