What is the Standards Improvement Initiative?
The Standards Improvement Initiative (SII) strives to improve The Joint Commission’s standards by:
- Clarifying standards language
- Ensuring that standards are program-specific
- Deleting redundant or non-essential standards
- Consolidating similar standards
- As additional benefits to users, the manuals will be reorganized and the scoring and decision process will be refined.
When will changes be implemented?
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. Beginning in 2008, The Joint Commission will seek feedback on standards for the behavioral health care, laboratory and long term care accreditation programs.
Why is the Joint Commission considering these changes?
The Joint Commission strongly believes it must continuously assess its standards to ensure their relevancy in a changing health care environment. The standards guide safety and quality of care efforts in more than 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 in the quality and safety of care.
Does the field have any input on this initiative?
Yes! This initiative includes a comprehensive engagement plan to ensure that the field has sufficient time to provide feedback. The Joint Commission is seeking 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 are gathered through on-line surveys, meetings, one-on-one interviews, and focus groups.
What are the specific benefits of the initiative?
- Standards, rationales and elements of performance will be easier for health care organizations to interpret and employ.
- Scoring will be simpler.
- The decision process will more accurately reflect organizational performance related to safety and quality of care.
- Manuals will be easier to navigate.
Will there be a 2009 manual that reflects the changes from the Standards Improvement Initiative? If so, when will it be available? And will there continue to be twice-a-year updates?
Ambulatory, critical access hospital, home care, hospital, and office-based surgery programs will have a 2009 manual. The Joint Commission is investigating ways to make the manual more user-friendly and easy to update. There has been a lot of interest in an electronic manual with electronic updates. The Joint Commission is conducted a cost-benefit analysis of electronic manuals and is developing a prototype. The 2009 manual will become available in the fall of 2008.
Will the standards for different settings of care within a program be separated from other standards? For example, will the ambulatory care standards be separated from the ambulatory surgical standards?
Yes, The Joint Commission is looking at building databases that would show the “core” standards and then those standards that are applicable to specific settings or services.
In the new manual, will there be a way to identify those standards that are common across programs, settings or services?
The Joint Commission is looking into ways to identify common standards.
Is the Joint Commission working with setting-specific experts to improve the standards?
Yes, 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 member organizations/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.
How will the chapters change?
The Joint Commission is looking at adding specificity to chapters, pulling out standards that are not relevant to the chapter, referencing or “linking” to other 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.
What is being done to improve scoring?
A subgroup of the Standards Improvement Initiative is concentrating on improving the scoring of the standards and EPs. The objective is to make sure that the standards and EPs are scored in a way that gives a valid accreditation decision, yet is simple and easily communicated. A scoring prototype, when developed, will be tested. Additionally, the Joint Commission is eliminating all compound sentences and all bulleted requirements. The goal is to make each EP speak to a very specific requirement.
Is anything being done to help with the documentation requirements?
Yes. The Joint Commission is considering including more icons to highlight requirements and to distinguish between documentation and planning requirements. The goal is to make the requirements very clear.
Also, the Joint Commission is looking at moving all of the requirements related to the medical record out of the IM chapter and either making them a subsection of the Provision of Care chapter or creating a separate chapter for them. The goal is to put everything related to the medical record in one place in the manual.
Is The Joint Commission looking at the Staffing Effectiveness Standards?
Yes. The Joint Commission is working to make those standards more relevant to organizations.
Is anything being done to better align the standards with the Centers for Medicare and Medicaid’s Conditions of Participation?
Yes! The Joint Commission is working with CMS to address this issue. The manual will clearly state where there are gaps or disagreements.
The Provision of Care chapter is particularly large; is anything being done to make it more manageable?
Yes. The Joint Commission is looking to break that chapter apart and to reduce redundancy within the chapter. The chapter may be broken into separate chapters or separate categories within a chapter. However, some chapters will still be larger than others, but the goal is to organize them in such a way that the user will find the structure more intuitive and easier to use.
Where can I get more information about the initiative?
The Joint Commission newsletters will have articles on this initiative.
How can I provide input on any proposed changes? Who do I contact with questions?