Applicable to Ambulatory Care Accreditation program
Effective immediately, The Joint Commission has revised three elements of performance (EPs) relevant to deemed-status ambulatory surgical centers (ASCs) in the Ambulatory Care Accreditation program. The changes align Joint Commission requirements with Centers for Medicare & Medicaid Services’ (CMS) revisions to several Medicare Conditions for Coverage for ASCs that published on October 14, 2011. The changes modify previous language that required ASCs to provide patients’ rights information to patients “prior to the date of their surgical procedure.” Based on feedback from ASCs, CMS determined that the previous regulatory language was overly restrictive in that it did not allow ASCs to continue to routinely perform same-day surgeries. The language also potentially affected a patient’s ability to obtain an elective, same-day, nonemergent surgical procedure. These revisions will appear in the 2012 Update 1 to the Comprehensive Accreditation Manual for Ambulatory Care and the E-dition®, scheduled for publication in spring 2012. The revised requirements are below; new text is underlined and deletions are noted in strikethrough.
LD.04.02.01, EP 6: For ambulatory surgical centers that elect to use The Joint Commission deemed status option: The ambulatory surgical center discloses, where applicable, physician financial interests or ownership in the facility in accordance with 42 CFR Part 420. This disclosure information is in writing, and is furnished to the patient in advance of the date of his or her procedure.
RI.01.01.03, EP 4: For ambulatory surgical centers that elect to use The Joint Commission deemed status option: The ambulatory surgical center provides the patient or his or her surrogate decision-maker with verbal and written notice of the patient’s rights in advance of the date of the procedure prior to the start of the surgical procedure and in a language and manner that the patient or his or her surrogate decision-maker understands.
RI.01.05.01, EP 7: For ambulatory surgical centers that elect to use The Joint Commission deemed status option: In advance of the date of the procedure, t The ambulatory surgical center provides the patient or his or her surrogate decision-maker prior to the start of the surgical procedure with verbal and written information concerning its policies on advance directives, including a description of applicable state health and safety laws and, if requested, official state advance directive forms.
(Contact: Joyce Webb, jwebb@jointcommission.org)