Please note:
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The form must be submitted by the accredited organization or health care system; forms submitted by consultants will not be accepted for consideration.
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The form should be submitted to The Joint Commission no less than 60 days prior to a scheduled survey.
Review of RFRs in relation to the survey
Members of the Patient Safety Advisory Group will review each form and advise The Joint Commission on the acceptability of the alternative. The organization will be notified prior to its scheduled survey whether its alternative is acceptable or not. If not accepted, the organization will be provided with the rationale and will need either to revise the alternative until it is approved, or to implement the requirement issued by the Joint Commission.
Surveyors will accept organizations' use of approved alternatives and will evaluate the implementation of those alternatives and other relevant requirements associated with the NPSGs.
If an organization is surveyed and has implemented an alternative that has yet to be reviewed, the surveyor will record the requirement as "non-compliant," include a description of the alternative, and identify that the alternative needs to be reviewed.
When the report is received at The Joint Commission's Central Office, the organization's account executive will begin or follow-up on the process for review of the alternative. Upon disposition by the Joint Commission, the organization's survey results will reflect either acceptance or rejection of the alternative. If the alternative is rejected, the organization will receive a special Requirement for Improvement for that NPSG and will be required to submit evidence of compliance with the NPSG.
For problems with the file download, e-mail webmaster@jointcommission.org.