Facts about the Intracycle Monitoring Process | Joint Commission
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Facts about the Intracycle Monitoring Process

March 9, 2017

The Joint Commission’s Intracycle Monitoring (ICM) process helps organizations with their continuous standards compliance efforts. Every accredited organization has access to an ICM Profile, an online workspace on The Joint Commission Connect™ extranet. The ICM Profile includes a list of high-risk topics and related standards, as well as resources and solutions to contemporary health care service challenges. Located within the ICM Profile, the Focused Standards Assessment (FSA) provides organizations with an easy-to-use, interactive standards self-assessment scoring tool. The FSA lists applicable standards customized to an organization’s accredited programs and services; standards linked to high-risk topics are displayed with an “R” icon for easy recognition. The FSA tool workspace permits an organization to develop and monitor corrective plans of action in order to sustain standards compliance.

ICM submission requirements
The Joint Commission requires all accredited organizations (except those accredited under the Office-Based Surgery Accreditation program) to acknowledge annual standards self-assessment activities during the intervening years between on-site full survey events (at 12 and 24 months of the triennial general accreditation cycle, or at 12 months of the biennial Laboratory Accreditation cycle). Organizations acknowledge their compliance with this requirement through one of four ICM Profile submission options:

Full

  • The organization uses the FSA tool to assess and score compliance with elements of performance (EP) for applicable standards. At least the minimum subset of R-icon standards must be scored in order to accomplish a Full submission. Data entered into the FSA tool is copied to a historical submission record for future reference by the organization.
  • For each EP scored not compliant, the organization creates a Plan of Action (POA) to restore the standard to full compliance.
  • A conference call can be requested by either the organization or the Standards Interpretation Group (SIG) to discuss submitted POAs or other standards-related issues.

Option 1

  • The organization submits an attestation to affirm it has completed a standards self-assessment process, including the development of appropriate POAs.
  • While organizations are encouraged to use the FSA tool to facilitate standards self-assessment activities, any data entered into the FSA tool is not copied to a historical submission record.
  • The organization can submit standards-related topics in the ICM Profile for telephone discussion with SIG, if desired.

Option 2

  • The organization submits a request for an on-site educational survey that includes documented findings (additional fees apply). 
  • A surveyor assists the organization in the review of organization-identified high-risk areas. Standards compliance issues are documented in the FSA tool for the organization’s follow-up action.
  • Within 30 calendar days after the on-site event, the organization submits POA information for standards identified by the surveyor as not compliant.
  • A conference call can be requested by either the organization or SIG to discuss submitted POAs or other standards-related issues.

Option 3

  • The organization submits a request for an on-site educational survey that does not include documented findings (additional fees apply). 
  • A surveyor assists the organization in the review of organization-identified high-risk areas, but does not enter data in the FSA tool.
  • Standards compliance information is provided to the organization through an oral exit briefing; there is no documented record of any event findings.

To learn more about the ICM/FSA process, please contact your organization’s designated account executive.

 
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