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Accreditation and Certification

May 17, 2017

Phased roll-out of newly redesigned ESC form to all programs

The Evidence of Standards Compliance (ESC) form has been redesigned by The Joint Commission to help organizations focus on detailing the critical aspects of corrective actions taken to resolve Requirements for Improvement (RFIs). The redesigned form was first used in surveys conducted in April for ambulatory care organizations and deemed psychiatric hospitals. By mid-year, it will be extended to all accreditation and certification programs.

The new form has required fields with lead-in statements that enable organizations to provide more specific information to better align with proven performance improvement methodologies. 

It also allows organizations flexibility to implement corrective actions within their unique environment, supported by the provision of program-specific examples that highlight key elements of effective compliance.

The previous format asked:

  • Who was ultimately responsible for the corrective action?
  • What actions were completed to correct each finding?
  • When were each of the actions completed?
  • How will compliance be sustained?

The redesigned format delves deeper into the specifics, regarding:

  • Assigning accountability by asking who is ultimately responsible for corrective action and sustained compliance.
  • Assigning accountability for leadership involvement by asking which member(s) of leadership support(s) future compliance.
    • Note: This is only for higher-risk RFIs (those placed within the dark orange and red areas of the SAFER™ Matrix)
  • Correcting noncompliance by asking what actions were taken to correct each finding, and when all the actions were completed (this is indicated with one final date). 
  • Correcting noncompliance via a preventative analysis by asking what analysis was completed to ensure not only that the noncompliant issue was corrected (surface/high-level resolution) but also any underlying reasons for the failure were addressed.
    • Note: This is only for higher-risk RFIs (those placed within the dark orange and red areas of the SAFER™ Matrix)
  • Ensuring sustained compliance by asking what:
    • Procedures/activities were identified to monitor compliance;
    • The frequency is of the monitoring activities;
    • Type of data will be collected from the monitoring activities, and how, and to whom, the data will be reported.

The form redesign is part of Project REFRESH, a process improvement initiative of The Joint Commission’s that is taking place over the course of 2017. One thing that isn’t changing is that organizations will still have a 60-day time frame to submit corrective actions. Organizations also can continue to access ESC guidelines and the submission process through their Joint Commission Connect™ extranet site. Questions about the redesigned ESC form should be directed to an organization’s account executive.

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