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RSS Feed RSS By: Michael Kulczycki, Executive Director, Ambulatory Health Care

Information on all things ambulatory from The Joint Commission

The Joint Commission. . . SAFER™ Than Ever!

May 17, 2017 | Comments (0) | 696 Views

By P.J. Sanders
Business Development Specialist
Ambulatory Care Services
The Joint Commission

The Joint Commission’s new process for helping health care organizations identify risk and improve their patient care processes – the Survey Analysis for Evaluating RiskTM (SAFERTM) Matrix – has been fully integrated with the Ambulatory Care Program’s accreditation program since the beginning of 2017.  An integral part of The Joint Commission’s multiphase Project REFRESH initiative, SAFER’s streamlined, innovative approach, applies to all Joint Commission accreditation and certification programs.

The SAFER Matrix (view SAFER Matrix Extranet Tool Video Demo below) replaces our former scoring methodology and allows our surveyors to place each Requirement for Improvement (RFI) within a matrix according to the issue’s likelihood to cause harm to patients, staff, or visitors, and according to the scope of the cited deficiency. It also allows for improved real-time, on-site evaluations of potential deficiencies.

Beyond SAFER
So, now that we have experience working with the new SAFER Matrix, let’s take a look at other REFRESH innovations underway. As you may recall, Project REFRESH is The Joint Commission’s multiphase process improvement project simplifying and modernizing various aspects of our pre-survey, on-site survey, and post-survey activities, intended to provide more transparency to the accreditation process. By any means, REFRESH is a successful undertaking, as indicated by the following:

  • Redesigned Evidence of Standards Compliance (ESC) form to help organizations better describe the critical aspects of their corrective actions and promote successful submission of ESCs.
  • Reduction in number of Elements of Performance (EP) Project eliminated 85 Ambulatory Care EPs and 50 Office-Based Surgery EPs, as explained in our last blog.
  • Phase IV of the EP Review Project will continue to consolidate or eliminate standards requirements across all accreditation programs.

Your Input Makes A Difference!
Through feedback gathered from you, our valued accredited ambulatory care customers, as well as insights from our Ambulatory Customer Advisory Councils, recent on-site surveys, and targeted market research, we’ve made significant positive changes to the on-site survey process which will continue to bear fruit in the months and years ahead.

Find in-depth information regarding the SAFER Matrix enhancements on the new SAFER informational portal or please submit your questions to




Fewer Ambulatory Care Standards... What’s Not to Like?

May 03, 2017 | Comments (0) | 1682 Views

By Joyce Webb
Project Director
Division of Standards & Survey Methods
The Joint Commission

By The Numbers
After a thorough review – which began with the Hospital program – The Joint Commission recently deleted 85 elements of performance (EPs) from the Ambulatory Health Care (AHC) accreditation program and 50 EPs from the Office-Based Surgery (OBS) program (see chart below). The deletions removed EPs that:

  • Were duplicative
  • Have been in place for years, but addressed concepts that are now a routine part of clinical operations
  • No longer addressed contemporary quality and safety concerns
  • Are adequately addressed by law and regulation or other external requirements

The Bottom Line
Frankly, we discovered these EPs were no longer needed. There a lot of things organizations do to make sure they provide safe and effective patient care, but not everything needs to be addressed through a Joint Commission requirement. The changes we’ve made here will help organizations focus on what’s most important. 


The new EP deletions will be effective July 1, 2017. A full list of the deleted AHC and OBS elements of performance is provided for your review in the May issue of our monthly newsletter, Perspectives.

Deletion Exceptions
Of course, not every EP deleted from the original review (impacting the Hospital program) carried over into the Ambulatory Care program. Some notable exceptions include the following:

  • In some cases, an EP that was deleted from the Hospital program had to be retained for Ambulatory Care because it is a specific Centers for Medicare & Medicaid Services’ (CMS) requirement (CMS requirements are not the same across all programs). 
  • Finally, there were some unique program issues that required retention of an EP that was deleted for hospitals.

We’re Pleased!
Michael Kulczycki, Executive Director, Ambulatory Care Services, observes “We know ambulatory care organizations are busier than ever and need to spend their valuable time delivering high quality patient care,  not fulfilling irrelevant standards. We’ve listened to customer requests for more appropriate and impactful standards and are pleased to further streamline our requirements.  This project – which fulfills the aims of simplification & relevancy – is one of many process improvement components of Project REFRESH.”

Stay tuned, there’s more to come… the next phase of this ongoing standards maintenance review will involve additional consolidations of existing requirements!

Top 10 Challenging Standards for 2016

Apr 13, 2017 | Comments (0) | 3482 Views

Frequent AmBuzz readers know it’s spring when The Joint Commission unveils an annual summary of the Top 10 Challenging Standards our Ambulatory Health Care (AHC) and Office-Based Surgery (OBS) accredited organizations experienced throughout 2016.

Our Ambulatory Care-specific customers may well recognize the Infection Control and Human Resources standards, because they have topped this list many times before. The Environment of Care standard is a newcomer to the group. This year’s most challenging standards are:

  1. IC.02.02.01 – The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
  2. HR.02.01.03 – The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.
  3. EC.02.03.05 – The organization maintains fire safety equipment and fire safety building features.

We’ve gathered advice from three seasoned Joint Commission professionals, well versed in the complexities of these requirements. Their professional insights might solve some of your most perplexing questions.

Lisa Waldowski, Infection Prevention Specialist, Standards Interpretation Group

IC.02.02.01 demands your attention as it directly impacts the care of your patient. Follow these guidelines to implement a smart, patient-first infection prevention process:

  • Train staff who perform high-level disinfection and sterilization to the appropriate competency
  • Assess competency of those with supervisory oversight to sign off and monitor staff conducting high-level disinfection/sterilization
  • Confirm the location of documented competencies
  • Ensure staff has access to the manufacturer instructions for use of instruments, equipment, and supplies used for high-level disinfection/sterilization
  • Procure the manufacturer instructions for use of the sterilizer, endoscope, or high-level disinfectant  [NOTE THIS IS MFU or “for use”]
  • Review evidence-based guidelines specific to high-level disinfection/sterilization with frontline staff, and ensure future access to updated guidelines
  • Perform staff teach-backs of evidence-based guidelines for high-level disinfection and/or sterilization 

Additionally, managers and supervisors should ensure quality monitoring processes are enforced. Some suggestions with examples of probing questions to help ensure compliance:

  • Can you ensure high-level disinfection/sterilization quality control requirements are rigidly followed and documented?
  • Do frontline staff utilize documentation logs for high-level disinfection or sterilization? Are the logs complete? Are there gaps? 
  • Do you ensure there is adequate space, equipment and supplies to conduct high-level disinfection/sterilization processes?
  • Is your process flow from dirty to clean in one direction, with no risk of cross-contamination?
  • Is there enough storage provided to store endoscopes? Are there enough surgical instruments to minimize the use of immediate-use steam sterilization (IUSS, formerly known as “flashing”)? 

Joyce Webb, Project Manager, Division of Standards and Survey Methods

HR.02.01.03 continues to be one of the top challenging standards for ambulatory care organizations. This standard is about verifying that licensed independent practitioners are adept at providing quality, safe patient care. It is one of the most important responsibilities of a healthcare organization. Some tips and strategies to ensure compliance include:

  • Designating a detail-oriented point person to handle credentialing and privileging tasks
  • Establishing a routine and standardized process for primary source verification and granting of privileges
  • Using a standardized personnel/credentialing file format
  • Closely monitoring timeframes for review and renewal of privileges, using a calendar or computerized prompts/reminders
  • Obtaining a written health attestation from all providers going through credentialing and privileging

For more information about tips for successful compliance with this HR standard, see the Credentialing & Privileging Tips booklet.

George Mills,  Director of Engineering, Standards Interpretation Group

EC.02.03.05 The first five Elements of Performance (EP) of EC.02.03.05 in this standard are focused on testing the fire alarm system and associated components. This is a significant concern to The Joint Commission as these tests affirm the reliability of the fire alarm system.  But what does that phrase “fire alarm system” mean?  Simply put:

  • The fire alarm system is the electronic and mechanical devices that, when fire or smoke is sensed, alert the occupants of a fire condition and at the same time notify responding agencies, such as the fire department. 

These alarm devices must be tested annually to ensure they work as designed and would notify staff to implement their fire plan, while contacting fire responders to come to the building.  Often, The Joint Commission’s Requirement for Improvement (RFI) cites a lack of inventoried devices or late testing.  The Joint Commission requires an inventory of devices for each of these EPs to ensure all devices are tested. 

For more information about testing these devices, see the Joint Commission Physical Environment Portal for a module on testing all the devices listed in EC.02.03.05.

We trust our experts’ ideas and insights will help you address these important standards and EPs as you work to maintain compliance in your own organizations (or achieve initial accreditation) throughout 2017!

Register Today for May 9-10 Ambulatory Care ‘Accreditation Essentials’

Apr 06, 2017 | Comments (0) | 1008 Views

Mary Fran ClancyBy Mary Fran Clancy
Program Manager Custom Education
Joint Commission Resources (JCR)

There are plenty of new developments at The Joint Commission that make it more important than ever to attend the Ambulatory Care “Accreditation Essentials” program, May 9-10, 2017.

This 2-day, solutions-based educational event addresses our ambulatory care requirements plus provides updates on Project REFRESH, the new process improvement initiative currently underway at The Joint Commission. 

Demystifying SAFER™ matrix

One of REFRESH’s first initiatives positively impacting ambulatory care is the new scoring methodology utilizing the SAFER™ Matrix. SAFER dramatically illustrates your survey results via a color-coded grid, clearly segregating criticality and scope of risks observed on survey.

As with all our professional education offerings, you’ll learn directly from Joint Commission’s ambulatory care field staff, bringing you their timely insights from “where the rubber hits the road”. You’ll also learn what you need to know about the 2012 Life Safety Code R and how it impacts the environment of care and life safety requirements in your facility from our engineers. A few of the key takeaways you’ll receive:

  • Updates on accreditation survey processes

  • Tips and strategies for addressing challenging standards

  • Real world’ surveyor stories, scenarios and examples

Gain Crucial Accreditation Insights

The “Accreditation Essentials” program is packed with relevant information for you to succeed with your organization’s’ initial and ongoing survey readiness. By attending, you will network with other quality and safety professionals, who like you, need to know the latest developments regarding the ambulatory care standards. 

At the conclusion of this program, participants will be able to:

  1. Identify the attributes of high-reliability organizations.

  2. Describe the components of high reliability and their interrelationships to the risk of zero patient harm.

  3. Recall key tips for practical approaches to establishing a safety culture and leadership support.

  4. Explain the benefit of using RPI and its tools in performance improvement activities in healthh care organizations.

By the end of conference, you’ll be able to:

  • Identify the hallmarks of a “highly reliable” organization

  • Describe the correlation between high reliability and zero patient harm

  • Develop practical approaches for establishing a leadership-supported safety culture

  • Understand the benefit of using RPI tools in performance improvement activities


Who should attend?  

It’s an opportunity for all RNs, MDs and administrators charged with maintaining compliance in the ambulatory environment, or seeking to learn more about the ambulatory care accreditation process. The following individuals will benefit from attending “Accreditation Essentials”:

  • Accreditation and survey compliance managers

  • Quality improvement staff

  • Risk managers

  • Infection preventionists

  • Safety officers

Continuing Education (CE) contact hours are also available for those seeking credit for attending this Accreditation Essentials program. 

To see a list of the seven bodies granting CE credit hours, review the full 2-day program agenda and register for our May 9-10 Ambulatory Care Accreditation Essentials Program.


Total Hip / Total Knee Replacement Certification Raises Bar for Orthopedic ASCs

Mar 21, 2017 | Comments (0) | 1100 Views

By Patrick Phelan
Executive Director
Hospital Business Development
The Joint Commission

As technology has enabled more procedures outside the acute-care setting, ambulatory surgery centers (ASCs) are providing even more advanced surgical care. 

Procedures such as hip and knee replacement, that just a few years ago required a hospital stay, are now being performed on an outpatient basis in the ambulatory care setting.  How can you ensure you are providing the best surgical care for your patients?

New ASC Certification Option
Many organizations have utilized Joint Commission’s Total Hip and Total Knee Replacement (THKR) Certification to help them shift to this new care paradigm.  This advanced orthopedic certification focuses on transitions of care from the pre-surgical orthopedic consultation through the ASC admission, rehabilitation activities, and the follow-up visit with the orthopedic surgeon.

The certification process helps you identify and measure areas for improvement.  Your organization will submit data, track progress and see how your orthopedic program improves in areas such as:

  • Surgical site infections
  • Fall rates
  • Improving patient education prior to discharge
  • Length of stay
  • Early ambulation
  • Pain management

Midwest ASC Success Story
In December 2016, I visited the first ASC in the nation to be certified by The Joint Commission for its THKR program.  Ohio Specialty Surgical Suites, in North Canton, Ohio, achieved its THKR certification late last year.

Because of the organization’s focus on addressing patients’ pre- and post-surgical conditions and safely returning patients to their normal activities of daily living, Ohio Specialty Surgical Suites patients who’d undergone total hip total knee replacement were pleased with their surgical experience.

We were thrilled at the positive patient feedback, and it aligns nicely with The Joint Commission’s goals for THKR, namely increasing focus on evidence-based patient care in pain management and functional improvements in mobility.


Ohio Specialty Surgical Suites clinicians were excited for the recognition and also appreciated the additional resources the Joint Commission offers through the certification process.

For ASC clinicians and managers, the certification:

  • Provides a pathway to excellence
  • Is a framework to improve surgical patient outcomes
  • Reduces variation in care delivery, reducing the risk of error
  • Organizes teams across the continuum of care
  • Offers a competitive edge in the ASC marketplace

I encourage you to demonstrate your organization’s commitment to continuous performance improvement by contacting the Joint Commission Certification Team today at