Revisions Announced System Accreditation Option

Policy Revisions Applicable to Ambulatory Care and Home Care

Effective January 2017, The Joint Commission has revised the System Accreditation Option for accredited ambulatory care and home care organizations. The System Accreditation Option involves awarding a single accreditation decision to a “system” — an organization that has a corporate office or a main site, with multiple sites under the auspices of the main site. Surveying the system entails a visit to the main site and visits to a selected sample of sites within the system; the sites are selected based on the size of the system and the risk level of the services provided. The recent revisions involve changes to the sampling methodology and extension survey policy.

Sampling Methodology
The first revision reduces the number of sites that must be reviewed in order to provide a credible evaluation of the system and render an accreditation decision indicative of the performance of the entire system. The table in the column at right identifies the number of sites that are required to be reviewed, based on whether the services provided are high risk or low risk. Please note that this methodology does not apply to ambulatory care sites providing surgery, general sedation, or moderate sedation. Any ambulatory care system site that provides surgery, general sedation, or moderate sedation must be surveyed. For lists of the types of sites determined to be high risk and low risk, please see lists below.

Extension Surveys
The second revision addresses the fact that, over time, systems may add more sites or expand their scope of services. These changes necessitate a determination of the point at which a system’s size and scope have changed sufficiently enough to warrant an additional survey. For systems providing what are considered high-risk services, The Joint Commission will review the composition of the system at two intervals (9 and 18 months) in the system’s three-year accreditation cycle to determine whether an extension survey of the system is warranted. For systems providing what are considered low-risk services, the system will be reviewed at the midpoint in its accreditation cycle. These revisions will be included in the fall 2016 E-dition update and the 2017 Comprehensive Accreditation Manuals for the ambulatory care and home care programs. Questions regarding the System Accreditation Option may be directed to an organization’s assigned account executive.

Sampling for System Surveys by Size
Note: All ambulatory care sites that provide general anesthesia, moderate sedation, or surgery are considered high risk
and will be sampled at a rate of 100%.

High-Risk Sites

Number of Sites in System: 75 or fewer
Survey volume: All sites up to 19

Number of Site in System: 76 or more
Survey volume: 25% of sites up to a maximum of 30 sites

Low-Risk Sites

Number of Sites in System: 200 or fewer
Survey volume: All sites up to 19

Number of Sites in System: 201 or more
Survey volume: 10% of sites up to a maximum of 30 sites

Sampling for System Surveys by Risk — Ambulatory Health Care
Note: All sites that provide general anesthesia, moderate sedation, or surgery are considered high risk and will be sampled at a rate of 100%.

High-Risk Services:

  • Cardiac catheterization and cardiology
  • Chiropractic medicine
  • Dentistry
  • Endocardiography
  • Endoscopy
  • ENT procedures
  • Freestanding ER
  • Gynecology and obstetrics
  • Hematology
  • Infusion therapy
  • Interventional radiological procedures
  • In vitro fertilization
  • Kidney care/dialysis
  • Lithotripsy
  • Mohs surgical procedures
  • Nuclear medicine
  • Oncology
  • Ophthalmic surgery
  • Oral maxillofacial surgery
  • Orthopedic surgery
  • Pain management (invasive)
  • Plastic surgery
  • Podiatric surgery
  • Radiation oncology
  • Short stay — observation/recovery/infirmary
  • Telehealth surgical
  • Urgent care
  • Urological procedures
  • Urology
  • Vascular medicine

Low-Risk Services:

  • Allergy
  • Alternative medicine
  • Anesthesia practice that provides only local anesthesia
  • Audiology
  • Cardiac practice (noninvasive)
  • Computed tomography
  • Computed tomography angiography
  • Convenient care
  • Dermatology
  • Diagnostic imaging
  • Direct primary care
  • Family practice
  • Gastroenterology
  • General practice
  • Internal medicine
  • Mammography
  • Magnetic resonance angiography
  • Magnetic resonance imaging
  • Nuclear cardiology
  • Neurology
  • Occupational/worksite health
  • Optometry practice
  • Orthopedic medicine
  • Orthotic/prosthetics
  • Otolaryngology
  • Pain management (noninvasive)
  • Pediatric medicine
  • Positron emission tomography
  • Pharmacy dispensary
  • Podiatry
  • Pulmonary medicine
  • Rheumatology
  • Sleep diagnostics
  • Ultrasound

Sampling for System Surveys by Risk — Home Care

High-Risk Services:

  • Apnea monitors
  • Biomedical vents maintenance
  • Compounding pharmacy
  • Freestanding ambulatory infusion

Low-Risk Services:

  • Clinical consulting pharmacy
  • Clinical respiratory
  • DMEPOS — in-home, facility-based, mail-order
  • HME
  • Home health/PCSS — skilled; PT, OT, ST, medical social, aides
  • Hospice — in-home, facility-based (freestanding and segregated units)
  • Long-term care pharmacy (SNF or VA setting)
  • Warehouse — storage only
  • Warehouse — clean/repair/test