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Ambulatory Buzz

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

Information on all things ambulatory from The Joint Commission

Don’t Hit the Snooze Button on Upcoming Sleep LCD Deadlines

Jul 12, 2017 | Comments (0) | 835 Views Kristen Witalka
Senior Business Development Specialist
Ambulatory Care Services
The Joint Commission
Changes Impact Hospital-Based Sleep Services
Early 2017 marked the beginning of significant changes within the sleep provider community. Certain Medicare Administrative Contractors (MACs) revised their local coverage determinations (LCDs), modifying policies regarding Medicare coverage for polysomnography and other sleep-specific studies. Previously, these MACs recognized both Joint Commission Hospital and Ambulatory Care Accreditation. While Joint Commission’s Hospital Accreditation was previously sufficient for reimbursement, it no longer meets these MAC requirements. Now, only Joint Commission Ambulatory Care Accreditation of hospital-based sleep services is acceptable to these specific MACs. 
It is common for MACs to develop LCDs but these recent revisions are catching many hospital-based sleep centers off-guard, leaving hospitals scrambling to comply with the LCD changes or risk denial of coverage for reimbursement of their Medicare patient’s sleep studies. 
The following MACs revised their LCDs impacting sleep centers in the following states:
  • Wisconsin Physician Services (WPS) impacts providers located in Indiana, Iowa, Kansas, Michigan, Missouri, and Nebraska. The original LCD revision effective date was February 16, 2017. 
  • CGS impacts providers located in Ohio and Kentucky. The original LCD revision effective date was March 6, 2017. 
  • Noridian impacts providers located in Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, and US Territories (American Samoa, Guam, and Northern Mariana Islands). The original LCD revision effective date was June 5, 2017.

Note: Hospitals that are part of health systems utilizing WPS, CGS, or Noridian as corporate Part B MAC may also be impacted.

Clarifications Issued
Before you lose sleep over these revisions, clarification statements for all three MACs have been issued, granting sleep centers 90 days to apply for accreditation and one year to achieve accreditation. 

“The Joint Commission advocated for the extensions to reduce provider burden during the transition from hospital accreditation to ambulatory accreditation for sleep centers.” 

Mark Crafton, MPA, MT (ASCP)
Executive Director, State & External Relations
The Joint Commission

In addition, hospitals in states under the jurisdiction of other MACs should look closely at ambulatory accreditation of their own sleep center, as the LCDs implemented by WPS, CGS and Noridian may become a model for other Medicare Part B carriers.  For WPS specifically, the grace period only applies to Joint Commission accredited hospitals seeking Joint Commission’s Ambulatory Care Accreditation. 
As a helpful reference to the upcoming accreditation deadlines, hospital-based sleep centers should be aware of the following due dates: 
Medicare Contractor Application Due Date     Accreditation Due Date   
WPS August 10, 2017 May 12, 2018
CGS August 9, 2017 May 11, 2018
Noridian September 20, 2017 June 22, 2018

Hospitals currently accredited under The Joint Commission’s Hospital Accreditation Program can request an Ambulatory Care survey specifically for their sleep services. Hospitals may use one of two options: 
  1. Request a Joint Commission Ambulatory Care extension survey
  2. Request that Joint Commission’s Ambulatory Care survey coincide with their next triennial resurvey. Survey options are a matter of timing and preference, and we can help guide hospitals who may have additional questions regarding the survey process. 

“We are happy to report that Feather River Sleep Medicine received our survey visit this week and we are now Joint Commission Ambulatory Care accredited.  Our surveyor’s knowledge of sleep medicine and his willingness to share best practices made the survey truly valuable. Thank you for your perseverance with Noridian on our behalf.”

Kathy Leppanen
Program Manager, Regulatory
Feather River Hospital

Resources Available
Rest assured, we have numerous resources available to customers impacted by these LCD changes:
  • We recommend you get started today by reviewing the Ambulatory Care standards. Please contact us directly and ask for complimentary access to “E-dition” – the electronic version of our standards – so you can begin assessing compliance. 
  • When ready to apply, Joint Commission accredited hospitals can work with their assigned Account Executive to update their current application and request the Ambulatory Care survey. 
Please note: Non-Joint Commission accredited customers can also request an application for survey. 
As always, you are encouraged to call your Account Executive at 630.792.3007 with any questions or concerns.

Keys to Better Environment of Care Compliance with EC.02.06.01 – Part 1

Jun 28, 2017 | Comments (0) | 1173 Views

By Kathy Tolomeo
Engineer, Standards Interpretation Group
The Joint Commission

From highly-specialized ambulatory surgery centers (ASCs) to busy community health centers, ambulatory health care organizations provide their services across a variety of patient care platforms. With patients frequently coming and going and more limited staffing and resources, it’s also no secret it can be especially challenging to ensure the quality and safety of care in an ambulatory care center.  
Compliance Challenges

One Joint Commission Environment of Care (EC) standard that has been particularly challenging for ambulatory care organizations is EC.02.06.01, which requires establishing and maintaining a safe, functional patient care environment.  During 2016, nearly 24% of surveyed ambulatory care organizations were found to be noncompliant with this environment of care standard — and some of its elements of performance (EPs) get more Requirements for Improvement (RFIs) than others. 

For example, approximately 16% of surveyed ambulatory care organizations were deemed noncompliant with EP 1: “Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, or services provided.”

EC.02.06.01 had an EP, EP 13 (which was incorporated into EC.02.05.01 as EP 16 in 2017), that required an organization to maintain:

  • ventilation
  • temperature
  • humidity levels

This EP garnered nearly a 9% noncompliance rate.

The following EPs are less commonly cited in surveys but are still occasionally problematic:

  • EP 7 requiring separate waiting and post-anesthesia recovery areas in ambulatory surgical centers that elect to use The Joint Commission deemed status option
  • EP 11 requiring suitable lighting
  • EP 20 requiring clean patient areas
  • EP 23 requires emergency access to all locked and occupied spaces

Given how crucial this environment of care standard is, it’s important for ambulatory care organizations to evaluate common issues that can:

  • prevent them from meeting their requirements
  • trigger noncompliant findings
  • compromise patient or staff safety in the physical environment.

Staffing Limitations

Our ambulatory Life Safety Code (LSC) specialists tell us EC.02.06.01 is vital – as well as problematic – for several reasons. Unfortunately, ambulatory centers that qualify as “ambulatory health care occupancies” very often do not have staff dedicated specifically to maintaining a safe environment, which makes it harder for these health care organizations to stay on top of potential issues.

Adding to the challenge is the fact that EC.02.06.01 and its EP 1 is a “catch-all” standard, meaning it lacks specific directives or details in its language, which can lead to misinterpretation and oversight. While EP 1 can encompass anything from having appropriate handwashing facilities, to removing any tripping hazards on the floor, its over-arching purpose is to alert the organization that it really needs to be looking at everything within the physical environment.  Many organizations make the mistake of using the EPs in EC.02.06.01 as a checklist, which means they may often cross off items too quickly. EP 1 requires a more thorough assessment and is often best evaluated during rounding and environmental tours.

We’ll continue to explore the challenges of EC.02.06.01 and offer more compliance tips in Part 2 of AmBuzz, with particular focus on how surveyors scrutinize this challenging Environment of Care standard. In the interim, find more compliance insights in the June 2017 EC News article “Upping the Score on Physical Safety.”

For questions regarding this EC standard or other ambulatory care standards, we suggest you check the Standards Interpretation Group (SIG) FAQs or call SIG staff directly at 630.792.5900, x3.

Infection Control Challenges: What They Reveal, How You Can Respond

Jun 14, 2017 | Comments (0) | 1815 Views

Lisa Waldowski By Lisa Waldowski, MS, APRN, CIC
Infection Control Specialist
Standards Interpretation Group
The Joint Commission

Leading the most recent list of the Top Ten Challenging Standards for accredited Ambulatory Health Care (AHC) customers over the last year is an infection control (IC) standard cited more than any other standard in 2016. 

The standard – IC.02.02.01, EP 2 – is: 

  • The organization reduces the risk of infections associated with medical equipment, devices, and supplies by performing a high-level disinfection and sterilization.

Spike in Related Potential Harm to Patients
Confusion surrounding this critical infection control and prevention standard has led in 2016 to 43% of our AHC organizations and 53% of our Office-Based Surgery (OBS) customers experiencing at least one non-compliant finding associated with IC.02.02.01, EP 2. Additionally, these findings – linked to lapses in high-level disinfection (HLD) and sterilization processes – are also associated with the highest-risk survey findings.

Careful review by The Joint Commission reveals that from 2013 through 2016, immediate threat to life (ITL) declarations directly related to improperly sterilized or HLD equipment increased significantly. 74 percent of all ITLs – across all accredited programs – were related to improperly sterilized or HLD equipment in 2016. This is a critical issue requiring a serious response.

Consequences of failing to manage these health care risks could result in adverse outcomes for ambulatory care organizations, including:

  • placing patients at risk for contamination
  • causing potential outbreaks
  • potential loss of Joint Commission accreditation
  • potential reversal of Centers for Medicare and Medicaid Services (CMS) certification status
  • negative publicity, lost business and a damaged reputation
  • litigation

The safety checklist for leaders provided in the recent Quick Safety #33 offers detailed ‘actions’ for ambulatory care organizations to take. Here’s a sampling:

Activity  Accountable Staff  Yes / No

Competency and training: Assure that staff who perform HLD and sterilization have been trained and are deemed competent to do so and those with supervisory oversight are competent to sign-off and monitor staff conducting HLD or sterilization.

What to ask: How often do you assess for staff competency? How are managers/supervisors deemed competent? Where are documented competencies kept?



Quality Monitoring: Assure that HLD and sterilization quality control requirements are rigidly followed and documented.

What to ask: Show me the documentation logs for HLD and/or sterilization. Are they complete? Are there gaps?

Frontline Staff and/or Managers/Supervisors














The significance of failing to address these issues cannot be understated. Breaches in equipment sterilization and HLD processes may result in outbreaks of HIV or hepatitis B. The transmission of bacterial infectious agents is also a real possibility, including multi-drug resistant organisms, E.coli, MRSA (methicillin resistant Staphylococcus aureaus) and Clostridium sordellii. Preventing the spread of these highly infectious agents is of critical importance.

What You Can Do

The Joint Commission offers several recommendations for improving your organization’s HLD and sterilization activities. Check out these suggestions from the June issue of Perspectives:

  • Follow current nationally recognized evidence-based guidelines specific to sterilization and HLD processes.
  • Verify that manufacturer’s instructions for use are readily available to staff and employed for all equipment, devices, and supplies requiring sterilization or HLD.
  • Create organizational policies and procedures for sterilization and HLD that are supported by manufacturers’ instructions for use and evidence-based guidelines.

And consider these key findings from non-compliant organizations (see more at Quick Safety #33):

  • Staff lack the knowledge or training required to properly sterilize or HLD equipment.
  • Lack of leadership oversight.
  • Sterilization or HLD of equipment becomes a low priority within the organization.
  • Processes for sterilization or HLD are not followed (i.e., staff take shortcuts).
  • The time frames for proper sterilization or HLD of equipment are not followed.
  • Facility design or space issues prevent proper sterilization or HLD of equipment (e.g., processing takes place in a small room that also is used for storage).

We strongly encourage you to take the time to review how your ambulatory care organization is addressing all of these critically important infection control and prevention issues.

For additional questions on this or any other accreditation-related issue, please contact your account executive at 630.792.3007.

New & Improved: Redesigned Post-Survey Process Form

May 31, 2017 | Comments (0) | 1556 Views

Caroline HeskettBy Caroline Heskett
Project Manager
Business Transformation
The Joint Commission

As part of The Joint Commission’s Project REFRESH multiphase process improvement project, we’re excited to present customers a redesigned Evidence of Standards Compliance (ESC) form this July. As with all Project REFRESH initiatives, our goals for the ESC revamp include streamlining, improving, and increasing the relevancy of the post-survey process for our accredited ambulatory care organizations.

ESC Redesign Implementation Timing

  • Implementation began with the Ambulatory Care Accreditation Program for surveys beginning on/after April 10, 2017.
  • If a survey includes the Ambulatory Care Accreditation Program, all other programs surveyed at that time will also utilize the new ESC form
  • Roll out to all other accreditation and certification programs is expected mid-year

The 411 on the Redesigned ESC Form
The redesigned ESC form focuses organizations on communicating critical aspects of corrective actions that resolve Requirements for Improvement (RFIs), as well as ensuring sustainability for those fixes. The new format clearly and concisely lays out expectations that align with proven performance improvement methodologies. Read more.

The previous ESC format has been simplified with sections for completion that provide guidance on key elements of effective corrective actions and sustainment.

  • Detailed instructions for completion of the form have been updated. Both the ESC form and instructions are still available in the current location, on The Joint Commission Connect™ extranet site within the “Survey Process” tab, “Post-Survey” column, and “Evidence of Standards Compliance” link.
  • An example of an acceptable ESC response aligned with the new form is included as guidance.

Additional resources are now available to outline the criteria for a successful ESC.

For additional information regarding the redesigned ESC form, please contact your organization’s assigned account executive at 630.792.3007.

The Joint Commission. . . SAFER™ Than Ever!

May 17, 2017 | Comments (0) | 1159 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