Based on feedback from our organizations, The Joint Commission is introducing several enhancements to our survey processes in 2025. These answer the call to modernize our tools, alleviate burden, and provide better communications tools for use across stakeholders within our organizations.
The enhancements, with program applicability, include:
- A more user-friendly, redesigned survey report optimized to share insights in a clear and prioritized way, including an executive summary, to help organizations better understand and address their survey findings. Applicable to all accredited, certified and verified healthcare organizations.
- An improved SAFER® Matrix will use short descriptors to supplement standard and element of performance (EP) numbers. This use of short names will make it easier for healthcare leaders to understand areas of strength and opportunity. Applicable to all accredited organizations.
- The new SAFER Peer Benchmarking tool shows how hospitals perform compared to peers. Hospitals can determine if their performance is better, the same or worse than other similar organizations based on size, services delivered, or other demographics. Applicable to accredited hospitals.
- An optional new process will allow organizations to upload survey-related documents during any survey type via their Joint Commission Connect®; extranet site. The easy access will make it more efficient for sharing documents during a survey. Applicable to hospital, critical access hospital, and hospital tailored accreditation programs.
- The for-cause survey process has been modified to help organizations better understand the process. The general reason for the survey will be communicated, survey plan discussed, and at the close surveyors will provide a verbal overview of observations. Applicable to all accredited, certified and verified healthcare organizations.
The Joint Commission will continue to work with our accredited and certified organizations to find high priority areas of opportunity to improve both the experience and the learnings from surveys and reviews to enable and affirm the highest standards of healthcare quality and patient safety for all.
Starting in January 2025, all Joint Commission-accredited, -certified, and -verified healthcare organizations will receive an enhanced survey report after any survey. (Note: In this article, the term survey refers to accreditation surveys and survey reports, as well as certification and verification reviews and review reports.)
This redesigned survey report is in a more user-friendly format, helping organizations better understand and address their survey findings. Key features of the newly redesigned survey report include:
- Survey findings organized by placement on the Survey Analysis for Evaluating Risk® (SAFER®) Matrix, with high-risk and/or widespread findings listed first.
- Clear identification of which survey findings will be addressed during each follow-up activity (if applicable).
- Brief descriptions (short names) of standards and elements of performance (EPs) to more easily understand their intent (the next issue of Joint Commission Online will include an article about short names).
- For organizations using The Joint Commission for deemed status purposes, clearer identification of the level of deficiency associated with Medicare requirements (Conditions of Participation [CoPs], Conditions for Coverage [CfCs], and Clinical Laboratory Improvement Amendments of 1988 [CLIA ’88]).
- An executive summary, which is a concise overview of survey findings and follow-up actions, all in one place (see the following figure for an example).
The redesigned report applies to all accreditation, certification, and verification programs for all types of surveys. Also, the survey report has been enhanced for both the preliminary report and the final accreditation and certification reports. In addition to the highlighted changes, the preliminary report will no longer be removed at midnight on the last day of survey; it will remain available to organizations until the final survey report is posted.
Organizations will continue to access their preliminary and final accreditation, certification, and verification reports via their Joint Commission Connect® extranet site.
Starting in January 2025, the Survey Analysis for Evaluating Risk® (SAFER®) Matrix, an essential part of The Joint Commission’s survey report for all accredited health care organizations, will include short descriptors or “short names” alongside the standard and element of performance (EP) numbers on the Matrix.
Using simple, short names in plain English to describe standards and EPs will help healthcare organizations more easily identify and understand areas for improvement. For example, in the following sample SAFER Matrix, “Reusable Equip Policy/Procedure” is the short name associated with Infection Prevention and Control (IC) Standard IC.04.01.01, EP 4. Another short name is “Completed Medical Records” for Record of Care, Treatment, and Services (RC) Standard RC.02.01.01, EP 2. These short names provide quick reference to the standard and EP’s intent. To understand the SAFER Matrix going forward, one does not need to know the standards and EPs by their numbers to understand the topics of the findings because the short names provide enough description for a quick reference.
Short names will appear on the SAFER Matrix on the daily briefing summary, as well as in the preliminary and final accreditation survey reports starting in January 2025. Short names for certification and verification will be included in the future as part of regular reviews and updates.
Have you ever wondered how your hospital’s survey results compare to other hospitals?
The Joint Commission is providing hospitals and health systems with a new benchmarking tool to compare the results of their survey events to their peers during their last survey. The tool is based on a quantitative summary of results derived from survey findings and placement within the Survey Analysis for Evaluating Risk® (SAFER®) Matrix. The SAFER Peer Benchmarking tool can help hospitals determine if their performance during a survey is better, the same, or worse than other similar organizations based on size, services provided, and other demographics.
Starting in January 2025, Joint Commission-accredited hospitals will be able to access the SAFER Peer Benchmarking tool via their Joint Commission Connect® extranet site. Report users will be able to see data only for organizations they are authorized to access. Any other information will not be identifiable or traceable to a particular organization.
Hospitals will be compared to peer organizations based on the primary hospital type, bed size, and location of the organization (for example, academic medical center, 300+ beds, urban setting). In addition to comparing overall survey performance, the benchmarking tool provides the ability to see how an organization scored compared to their peers in key areas such as Leadership, National Patient Safety Goals, and Medication Management. Comparison of how an organization performed relative to similar organizations offers hospitals the opportunity to pinpoint where they may want to focus in the future.
Although healthcare organizations are encouraged to fully use the tool, the comparison data are intended for the exclusive internal use of Joint Commission-accredited organizations, and they may not include the benchmarking data externally in communications, marketing, or other promotions. For example, a hospital may not claim it is “in the top 95th percentile” based on the tool. The Joint Commission will not publish any traceable benchmark data publicly.
For more information about SAFER Peer Benchmarking, contact your account executive.
DISCLAIMER: SAFER Peer Benchmarking is not intended as evidence that an organization provides better healthcare or services than another organization. Users are fully responsible for expert analysis and confirmation that an organization is properly following laws, rules, and regulations related to healthcare quality and patient safety.
The Joint Commission has added an optional document upload process for hospital, critical access hospital, and hospital tailored accreditation programs. Organizations now can upload survey-related documents to their Joint Commission Connect® extranet site during any survey type. The optional document upload feature will do the following:
- Introduce efficiencies for document sharing during a survey
- Create a consistent location for requested documentation
- Provide seamless access to documents during survey activities
- Be a more environmentally sustainable approach to survey documentation
The Joint Commission will provide easy access to the folder(s), so a Joint Commission Connect user can upload documents if they have been granted security rights by their organization’s security administrator (Security Admin) for document upload. If your hospital or critical access hospital has additional programs being surveyed at the same time, a document upload folder will be provided for each program. Starting now, any hospital or critical access hospital can upload survey documents to their Joint Commission Connect extranet site.
Document Upload is available via the Joint Commission Connect extranet site under the “Survey Process” tab by clicking on the Document Upload link (as shown in the first image). Document Upload is also available from the Notification of Scheduled Events section using the Survey Documents link (as shown in the second image). The Document Upload link will become available at the initiation of the survey.
To prepare for this change, The Joint Commission recommends reviewing the “Security Admin” tab on your organization’s Joint Commission Connect extranet site. Users who will be uploading documents for any program must have their security rights changed to “Full” (as shown in the third image). The Primary Accreditation Contact and CEO roles have been granted “Full” security rights by default.
For any questions regarding this process, please contact your account executive.
COMING SOON: Required document upload: Behavioral Health and Human Services and Telehealth programs
Coming soon, freestanding behavioral health care and human services organizations, as well as freestanding telehealth organizations, will upload required survey documentation to their Joint Commission Connect extranet site prior to their triennial survey. Further details on this change will be provided soon to applicable organizations.
Effective immediately for all accredited, certified, and verified health care organizations, The Joint Commission has modified its survey processes to help organizations better understand a for-cause survey. Specifically, when a complaint is submitted about an organization resulting in a for-cause survey, The Joint Commission is now providing transparency about the areas of the organization to be surveyed. Surveyors will review the plan for the day, introducing the general reason for the survey, without revealing the specific details of the allegation to the organization unless confidentiality has been waived.
At the close of the visit, surveyors will provide a verbal overview of observations, including the associated chapters from the appropriate accreditation, certification, or verification manual, allowing the organization to ask questions or clarify any information.
The Joint Commission has removed from the 2025 ORYX®; program an optional inpatient measure, the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults, Hospital Level — Inpatient, (IP-ExRad). The IP-ExRad measure was on the list of optional measures organizations can select from to meet the ORYX requirement to report self-selected eCQMs. We are removing the measure due to a specification issue in the 2025 measure specifications (IP-ExRad version CMS1074v2).
Joint Commission technical staff identified that the measure specification does not match the measure intent and creates significant burden for implementers, including The Joint Commission, vendors, and hospitals. The Joint Commission team will continue to work with the measure developer and stakeholders and consider implementing the measure once the specification is corrected. The Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computer Tomography (CT) in Adults, Hospital Level — Outpatient (OP-ExRad) does not have this technical issue and will remain on the list of optional measures available for organizations to select to meet eCQM reporting requirements.
Organizations that considered or selected this measure please reach out to our customer support team directly for additional assistance or with any questions at HCOOryx@jointcommission.org.
Questions related to the ExRad eCQM specifications, logic, data elements, standards or resources can be submitted to the ONC JIRA CQM Issue Tracker.
Join The Joint Commission, Centers for Medicare & Medicaid Services (CMS), Mathematica, and measure stewards for the Expert to Expert webinar series, which addresses the electronic clinical quality measures (eCQMs) annual updates and introduces new eCQMs for 2025 implementation.
Common questions from JIRA and other sources will be addressed. Continuing education credits (CEs) are offered for the webinars in this 2025 reporting year series that addresses eCQMs for Stroke (STK); Venous Thromboembolism (VTE); Perinatal Care-Cesarean Birth (PC-02) and -Severe Obstetric Complications (PC-07); Hospital Harm-Opioid-Related Adverse Events (HH-ORAE); Global Malnutrition Composite Score (GMCS); Hospital Harm-Pressure Injury (HH-PI); Hospital Harm Glycemia-Severe Hyperglycemia (HH-Hyper) and -Severe Hypoglycemia (HH-Hypo); Safe Use of Opioids-Concurrent Prescribing; Acute Kidney Injury (HH-AKI); and Excessive Radiation (IP-ExRad).
Registration is now open for the following webinars and additional registrations will open soon. Bookmark this link to access registrations as they open: https://www.jointcommission.org/measurement/quality-measurement-webinars-and-videos/expert-to-expert-webinars/#sort=%40resourcedate%20descending See the registration pages for details on CEs and learning objectives.
See the registration pages for details on CEs and learning objectives.
Perinatal Care (PC) eCQMs: Cesarean Birth (PC-02) and Severe Obstetric Complications (PC-07)
Date: Jan. 9, 2025
Register: https://register.gotowebinar.com/register/2020943497010100060
Hospital Harm-Opioid-Related Adverse Events (HH-ORAE) eCQM
Date: Jan. 16, 2025
Register: https://attendee.gotowebinar.com/register/6288118437595289181
Global Malnutrition Composite Score (GMCS) eCQM
Date: Jan. 23, 2025
Register: https://attendee.gotowebinar.com/register/1278037575619576158
NEW for 2025 – Hospital Harm-Pressure Injury (HH-PI) eCQM
Date: Jan. 30, 2025
https://attendee.gotowebinar.com/register/881574573364658013
Hospital Harm Glycemia eCQMs: Severe Hyperglycemia (HH-Hyper) and Severe Hypoglycemia (HH-Hypo)
Date: Feb. 20, 2025
https://attendee.gotowebinar.com/register/772119290554678106
Safe Use of Opioids-Concurrent Prescribing eCQM
Date: Feb. 27, 2025
https://attendee.gotowebinar.com/register/6313088347522742871
An on-demand webinar produced in collaboration with the American Heart Association (AHA) is now available that provides an overview of the new measurement requirements effective Jan. 1, 2025, for The Joint Commission’s Advanced Certification in Heart Failure (ACHF) organizations.
The webinar covers the following components of the measure specifications: structure and clinical significance of the new required Get With The Guidelines-Heart Failure (GWTG-HF) measures; data elements and definitions; and measure algorithm logic.
Participant learning objectives are:
- Describe the intent and logic underlying the updated ACHF measure set.
- Utilize the information provided to understand the clinical significance of new required GWTG-HF measures and answer questions to inform measure use and implementation.
- Facilitate their organization’s implementation of the ACHF measure specifications.
This webinar is approved for 1 continuing education (CE) credit or Qualifying Education Hour until Feb. 12, 2025.
The Joint Commission and Kaiser Permanente are pleased to announce Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) as the recipient of the 2024 Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity. This prestigious award, established in honor of late Kaiser Permanente Chairman and CEO Bernard J. Tyson, honors a healthcare organization for its efforts that achieved a measurable, sustained reduction in one or more healthcare disparities.
The award recognizes ZSFG, a safety net hospital and San Francisco’s only Level 1 trauma center, for its achievements under the initiative Reducing Racial Disparities for African American Patients with Heart Failure. The improvement team’s efforts significantly improved care for all patients with heart failure at ZSFG.
As a result of their efforts, ZSFG:
- Closed the 5.4% readmission rate gap between Black/African American patients with heart failure and the general heart failure population.
- Decreased the 30-day readmission rate for all patients with heart failure from 33% to 20%.
To learn more about ZSFG’s achievement, the Tyson Award program, and other healthcare organizations focusing on healthcare equity, visit The Joint Commission's website.
Joint Commission Resources is seeking an enthusiastic and energetic Deputy Editor with experience in academic publishing, either as an editor or as an author, for the Joint Commission Journal on Quality and Patient Safety, a peer-reviewed publication. The Journal is growing in scope and impact and is dedicated to elevating innovative solutions; examples of scalable, successful implementation; editorials; and case reports designed to support healthcare professionals in providing high quality, safe care to all patients.
Applicants should hold a doctoral degree in a healthcare field and should have experience in quality improvement and patient safety. As part of our team of Deputy Editors, this role will share responsibilities for strategic direction of the Journal, handling the peer review and revision of submitted articles, soliciting papers and editorials, and ensuring that each issue meets our rigorous editorial standards.
Interested applicants should email their CV and a brief letter of interest to Senior Managing Editor Dojna Shearer, dshearer@jcrinc.com, by Jan. 24, 2025.