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Reducing the Burden: Eliminating 168 Accreditation Requirements Is Just the Start


By Kathryn Petrovic, MSN, RN, Director, Department of Standards and Survey Methods

The healthcare landscape is evolving, generating new and unprecedented challenges for health systems to manage, such as fallout from a global pandemic, workforce and drug shortages, clinician burnout, and more. But The Joint Commission’s dedication to improving patient care remains steadfast. This means we must evolve, too, meeting the moment and partnering with stakeholders to drive optimal care and value – a top priority of Joint Commission President and Chief Executive Officer Dr. Jonathan Perlin.

What’s new?
The Joint Commission is eliminating 168 accreditation requirements that are above and beyond regulations from the Centers for Medicare & Medicaid Services (CMS) or any other state or federal agency. In addition to eliminating roughly 14% of the standards within our scope, we are revising an additional 13 standards. This is just the start, as additional tranches of discontinued or revised standards will be announced in the months to come. 

Why now?
The Joint Commission is streamlining requirements to reduce the burden on health systems. We aim to help customers face the unprecedented challenges of the moment by removing requirements that do not add value during the accreditation process. The focus on fewer, more meaningful requirements means healthcare organizations and surveyors can concentrate on the standards that have a maximum impact on patient safety, quality and equity during our survey process. 

Who is affected?
The revisions affect 182 standards across all accreditation programs. Fifty-six Hospital standards were identified for deletion, with four additional standards being revised to make them more effective. Related reductions and revisions will apply to the following accreditation programs: Critical Access Hospitals (37 deleted, 4 revised), Ambulatory Health Care (20 deleted, 1 revised), Behavioral Healthcare and Human Services (9 deleted, 1 revised), Home Care (10 deleted, 1 revised), Laboratory Services (6 deleted, 1 revised), Nursing Care Centers (12 deleted), and Office-Based Surgery (18 deleted, 1 revised).

How were affected standards identified?
The review first focused on requirements that met three criteria:

  • Does not support a CMS regulation or state regulation.
  • Has been in effect for at least three years.
  • Has been scored five times or less during full triennial surveys between 2017 and 2019 (the three years prior to the COVID-19 Public Health Emergency).

The Joint Commission reviewed each element of performance (EP) that met these criteria to identify reasons for low scores, including:

  • If the EP had been standardized by organizations leading to broad compliance.
  • If the EP was redundant.
  • If compliance with the EP was difficult to objectively and consistently assess.

CMS approved the recommended discontinued standards after confirming they do not diminish any CMS regulatory requirements.

When will this change take place? How can I learn more?
The revisions and reductions will be effective February 19, 2023.For more information, please see the latest E-dition® or accreditation manual. 

What’s next?
During the initial review, some requirements met the deletion criteria, but were identified as requiring more research before a decision to keep or remove the standard could be made. This additional review is currently ongoing. 

Additionally, The Joint Commission has fully revised its “Emergency Management” (EM) chapter to streamline requirements, including:

  • Reorganized requirements
  • Renumbered standards
  • Reduction in EPs

The revision led to the reduction of more than 50% of EM requirements for hospitals and critical access hospitals and more than 30% of EM requirements for home care organizations, effective July 1, 2023. 

The Joint Commission will continue to review its standards, including those undergoing further review. We anticipate the second tranche of discontinued or revised standards will be announced later this year. We also will continue to review the EM chapter for all remaining accreditation programs. 

We believe all of these standards changes will allow us to have fewer, more meaningful requirements to best support our accredited organizations and their efforts to improve patient safety and quality of care for all.

Kathryn Petrovic, MSN, RN, is the Director of the Department of Standards and Survey Methods in the Division of Healthcare Quality Evaluation at The Joint Commission. In this role, she oversees the development and revision of the standards for all accreditation and certification programs. Petrovic was previously a Field Director in the Department of Surveyor Management and Development and a Senior Associate Director in the Standards Interpretation Group at The Joint commission. Prior to joining The Joint Commission, Petrovic was a nurse leader at several healthcare organizations.