The Joint Commission launched the Standards Improvement Initiative (SII) in October 2006 as part of its continuous effort to improve the standards. Improvements, both format and language changes, went into effect January 1, 2009 for the Phase I programs — ambulatory, critical access hospital, home care, hospital, and office-based surgery. The 2009 accreditation manuals for these programs include the SII improvements. These manuals are also available as electronic “E-ditions.”
Work continues on the Phase II programs — behavioral health care, laboratory, and long term care. The 2009 accreditation manuals for these programs include changes to the Leadership and Life Safety Code standards. Phase II implementation is planned for 2010, and the 2010 pre-publication versions of the accreditation requirements chapters are posted on The Joint Commission Web site. (Note: SII-related improvements to the Provision of Care, Treatment and Services Chapter for behavioral health care only, will be implemented at a later date.)
Current accomplishments of SII:
- Standards were revised and reorganized ― making them clearer, eliminating redundancies and creating a simpler, more logical order.
- Standards were renumbered and reordered to allow electronic sorting for the E-dition and to allow for the addition of new requirements in the future.
- Some elements of performance (EPs) were eliminated and others were redistributed (typically, bulleted EPs with multiple requirements).
- Icons were added to provide a guide to the requirements and scoring categories.
- New scoring and decision processes were implemented based on a “criticality model,” i.e., how critical an issue is to patient care or safety, as identified by noncompliant standards. The more critical the issue, the shorter the time frame that an organization has to address it. The levels of criticality fall into four categories:
- Immediate Threat to Health and Safety
- Situational Decision Rules ― e.g., loss of a facility license, Life Safety CodeÒ deficiencies, or care provided by unlicensed practitioners
- Direct Impact Requirements ― noncompliance is likely to create an immediate risk to patient safety or care
- Indirect Impact Requirements ― no immediate risk, but noncompliance increases the risk to the patient over time
The new scoring and decision methods became effective January 1, 2009 for all accreditation and certification programs.
- Numerical scores are no longer reported to the organization or public, which shifts the focus from “passing the exam” to continuous operational improvement.
- The supplemental section in the Accreditation Report (now called Survey Findings Report) has been eliminated. All findings of less than full compliance require resolution via submission of Evidence of Standards Compliance.
- The use of “thresholds” to determine Conditional Accreditation and Preliminary Denial of Accreditation has been revised. Instead, program-specific thresholds serve only as “screens” for identifying organizations whose survey findings require more extensive review by Joint Commission Central Office staff. The screens are based on the number of Direct Impact Requirements that are noncompliant.
For more information
Visit the SII webpage. Questions can be sent to standardsimprovement@jointcommission.org, or contact Carol Gilhooley, director, Division of Standards and Survey Methods, at (630) 792-5270.