Joint Commission Online - Jan. 24, 2024
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
January 24, 2024
Effective July 1, 2024, a fully revised Emergency Management (EM) chapter, including new and revised EM standards, has been approved for all Joint Commission-accredited ambulatory care organizations and office-based surgery practices. The Joint Commission thoroughly analyzed and rewrote the EM chapter, which resulted in the following:
- Reorganized requirements
- Renumbered standards
- Reduced elements of performance (EPs) by more than 40% for ambulatory care organizations
- Eliminated redundant requirements for office-based surgery practices
The goal of the rewrite was to help health care organizations to develop more comprehensive EM programs and to better prepare for the health, safety, and security needs of their facilities, staff, patient populations, and communities during emergencies or disasters (such as the COVID-19 pandemic). The new and revised EM requirements clarify and emphasize the following:
- Assessment, applicability, and incorporation of the hazard vulnerability analysis throughout the EM chapter
- Leadership involvement and oversight in all aspects of the EM program
- Staff education and training, with specific guidance for initial and ongoing EM training
As a result of the EM revisions, the following changes also apply:
- Information Management (IM) Standard IM.01.01.03, EPs 5 and 6, will be deleted from the ambulatory care requirements.
- There will no longer be requirements specific to Federally Qualified Health Centers (FQHCs). Those organizations will follow the EM requirements on the applicability grid for either medical centers or dental centers, as applicable.
- Rural health clinics (RHCs) accredited under the ambulatory care program will follow the EM requirements identified by the lead-in for RHCs, beginning at Standard EM.02.01.01 and ending at Standard EM.04.01.01, until further notice.
The program-specific R3 Report provides rationales for the requirements as well as references to the research and reports used to develop them. In addition to an extensive literature review, the new and revised requirements were developed based on voice-of-customer feedback resulting from the pandemic, public field review, and expert guidance from the standards review panel and an internal Joint Commission EM workgroup.
The new and revised standards will be posted on the Prepublication Standards page of The Joint Commission’s website and will publish online in the spring 2024 E-dition® update to the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) and the Comprehensive Accreditation Manual for Office-Based Surgery Practices (CAMOBS).
For more information, please contact the Department of Standards and Survey Methods.
January 24, 2024
Effective July 1, 2024, The Joint Commission approved revisions to its requirements for the Post-Acute Care add-on certification option for nursing care centers (NCCs). These revisions include the following:
- Five new elements of performance (EPs)
- 11 revised EPs
- Six consolidated EPs
- 18 EPs with editorial changes
- Seven deleted EPs
The new and revised requirements are designed to improve the safety and quality of care for patients or residents receiving post-acute care in Joint Commission-accredited NCCs. The updates reflect the most recent clinical practice guidelines from the American Medical Directors Association’s Society for Post-Acute and Long-Term Care Medicine; feedback from Joint Commission-accredited NCCs, including those with and without Post-Acute Care certification; and recommendations from subject matter experts in rehabilitation and long-term care. The revised requirements cover topics in the Human Resources (HR), Leadership (LD), Provision of Care, Treatment, and Services (PC), and Performance Improvement (PI) chapters.
The revised requirements will be posted on the Prepublication Standards page of The Joint Commission’s website and will publish online in the spring 2024 E-dition® update to the Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC).
For questions regarding the revisions, please contact the Department of Standards and Survey Methods.
January 24, 2024
Registration is now open for an Expert to Expert webinar on New Measure Review of the Global Malnutrition Composite Score (GMCS) eCQM. The webinar is on Feb. 22, 2024, at noon Eastern | 11 a.m. Central | 10 a.m. Mountain | 9 a.m. Pacific.
Questions from JIRA and other sources will be addressed. Additionally, participants will be invited to submit questions for response by subject matter experts during a live Q&A segment. The learning objectives are:
- Navigate the eCQI Resource Center website to locate measure specifications, value sets, measure flow diagrams and technical release notes.
- Apply concepts learned about the logic and intent for the GMCS eCQM.
- Prepare to implement the GMCS eCQM for the 2024 eCQM reporting period.
- Identify common issues and questions regarding the GMCS eCQM.
Slides will be available for download from within the webinar platform approximately one hour before the broadcast begins. The recording, slides, and Q&A document will be available on The Joint Commission website within several weeks of the broadcast, following CMS approval. The webinar is approved for continuing education (CE) credit.
January 24, 2024
Time is running out to get continuing education (CE) credit for a free, on-demand webinar on the Joint Commission’s new voluntary Sustainable Healthcare Certification (SHC) program and its requirements. CE credits are available for viewing the webinar until 11:59 p.m. CT on Feb. 9, 2024.
The SHC program, which became effective Jan. 1, 2024, evaluates whether hospitals and critical access hospitals have established and implemented key structures and processes to improve energy efficiency, decrease their carbon footprint, and decrease waste. The framework of this new certification requires hospitals to:
- Identify environmental sustainability and decarbonization as a strategic priority and allocate the resources needed to achieve and sustain its goals to improve its environmental footprint by reducing its greenhouse gas emissions.
- Measure greenhouse gas emissions and develop goals and action plans to reduce emissions.
The webinar introduces each Standard and Element of Performance, offers examples for how they would be applied, and highlights resources available to assist organizations wishing to adopt these sustainable practices and requirements.
To receive CE credit, webinar participants also will be required to review the Sustainable Healthcare Certification Prepublication Standards (the link is provided to registrants).
January 24, 2024
The Commission on Accreditation of Healthcare Management Education (CAHME) and The Joint Commission have awarded their first Fellowship Award for Advancing Sustainable Health Care to Sadie M. Joba, a Master of Science (MS) in Health Systems Management candidate at Rush University. Sadie is dedicated to sustainability and envisions a healthcare landscape that prioritizes quality and safety while fostering environmentally responsible practices.
Beginning July 1, 2024, the fellow will be embedded into The Joint Commission’s operations, observing and participating in activities that support quality and safety in hospitals and other healthcare organizations. The fellowship includes:
- Working on initiatives that assist The Joint Commission in meeting its White House/U.S. Department of Health and Human Services (HHS) Health Sector Pledge to reduce emissions
- Supporting the rollout of Sustainable Healthcare Certification to all U.S. hospitals and critical access hospitals
- Learning The Joint Commission’s evaluation process
- Serving as an observer on a CAHME site visit
- Training on CAHME standards and processes
Established in November 2023, the award is a one-year, full-time paid fellowship awarded for advancing sustainable health care. The fellowship was established in recognition that sustainability, a well-educated workforce, and health care quality and safety have a broad and all-encompassing impact on the health of the community.
More information about the fellowship is available at the CAHME website.
January 24, 2024
The 2024 Joint Commission and CMS Crosswalk: Comparing Hospital Standards and CoPs is now available. The crosswalk provides the full and current language of the Medicare hospital Conditions of Participation (CoPs) and demonstrates how The Joint Commission’s hospital standards are equivalent to the CoPs.
Key features include:
- Authoritative, side-by-side comparison of Medicare CoPs to equivalent Joint Commission standards, for both hospitals and psychiatric hospitals.
- The only crosswalks of their kind reviewed and approved by The Joint Commission and CMS.
- Reverse crosswalk listing Joint Commission hospital and psychiatric hospital requirements with comparable CoP numbers, showing equivalencies in the opposite direction — not found anywhere else.
- New! A summary of CMS changes affecting hospitals over the past year.
Get more information or order on JCR’s webstore.