Joint Commission Online - Dec. 21, 2022
EDITOR’S NOTE: Joint Commission Online will not publish on Dec. 28. Look for the weekly e-newsletter to return on Wednesday, Jan. 4. Happy holidays!
Joint Commission announces major standards reduction, freezes hospital accreditation fees to provide relief to healthcare organizations
December 21, 2022
The Joint Commission is eliminating 168 standards (14%) and revising 14 other standards across its accreditation programs to streamline requirements and make them as efficient and impactful on patient safety, quality and equity as possible. Additionally, The Joint Commission is not raising its accreditation fees for domestic hospitals in 2023 in recognition of the many financial challenges hospitals and health systems continue to face.
The first tranche of standards deletions and revisions by program will be effective Jan. 1, 2023. They include:
- Hospital: 56 deleted and 4 revised
- Critical Access Hospital: 37 deleted and 4 revised
- Ambulatory Health Care: 20 deleted and 1 revised
- Behavioral Health Care and Human Services: 9 deleted and 1 revised
- Home Care: 10 deleted and 1 revised
- Laboratory Services: 6 deleted and 1 revised
- Nursing Care Center: 12 deleted and 1 revised
- Office-Based Surgery: 18 deleted and 1 revised
The standards reduction is the result of The Joint Commission’s comprehensive review that was announced in September 2022. The Joint Commission reviewed all its “above-and-beyond” requirements – those that go beyond regulatory requirements of the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and are not on crosswalks to the CoPs. Specifically, The Joint Commission reviewed each standard to answer:
- Does the requirement still address an important quality and safety issue?
- Is the requirement redundant?
- Are the time and resources needed to comply with the requirement commensurate with the estimated benefit to patient care and health outcomes?
In addition to a direct review of each standard, The Joint Commission conducted quantitative analyses of scoring patterns and tested for redundancy. Where necessary, it also led literature and field reviews and engaged experts within the field.
CMS approved the recommended discontinued standards after confirming they do not diminish any CMS regulatory requirements. Importantly, a second tranche of standards is under consideration for elimination or revision, and a second announcement of burden reduction is anticipated in approximately six months.
“The standards reduction will help streamline Joint Commission requirements, as well as provide some much-needed relief to healthcare professionals and organizations as they continue to recover from the pandemic,” said Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI, president and chief executive officer, The Joint Commission. “Our goal is to eliminate any standard that no longer adds value. We want to have fewer, more meaningful requirements that best support safer, higher-quality and more equitable health outcomes.”
To further provide relief to hospitals and health systems, The Joint Commission will not raise domestic hospital accreditation fees in 2023. As a result, some accreditation surveys will be conducted for less than cost.
“As with so many other organizations, we are experiencing inflation in several areas of our business, notably travel costs for surveys, however, we are steadfast in our decision not to raise domestic hospital accreditation fees,” Dr. Perlin added. “We believe this is the right thing to do and look forward to further supporting our accredited healthcare organizations in 2023.”
December 21, 2022
New requirements on healthcare equity will be found in Leadership (LD) Standard LD.04.03.08 and will apply to Joint Commission-accredited hospitals, critical access hospitals, ambulatory care organizations, and behavioral healthcare and human services organizations. These will be effective Jan. 1, 2023.
However, applicability is not accurately shown in the fall E-dition® update and print versions of the Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) and the Comprehensive Accreditation Manual for Hospitals (CAMH).
The new standard and elements of performance (EPs) are erroneously not shown as applicable to long-term acute care (LTAC), psychiatric, surgical specialty, and swing bed services on E-dition or in hard-copy or digital versions of the CAMCAH and CAMH, and the EPs are not marked as applicable to those services in the “Standards Applicability Grid” (SAG) chapter of the hardcopy or digital versions of the CAMCAH and CAMH. However, these requirements do apply to all services in the critical access hospital and hospital programs.
Applicability will be revised in the interim winter 2023 E-dition update in February. For those customers who purchase it, the hardcopy spring update of the CAMH will include the revised SAG chapter.
Questions may be directed to the Department of Standards and Survey Methods.
December 21, 2022
Improvement Insights — Providing Palliative Care to Patients Throughout the State of Indiana from a Centralized Virtual Palliative Care Hub: Researchers sought to ease these burdens and expand the accessibility of palliative care throughout Indiana through a centralized virtual hub. Their experiences are described in a manuscript published in the December 2022 issue of The Joint Commission Journal on Quality and Patient Safety.