The Joint Commission added several new and revised elements of performance (EPs) for critical access hospitals (CAHs) that primarily address restraint and seclusion, the complaint process, and unified and integrated structures for critical access hospitals that are part of a multihospital system.
These changes — which are effective June 1 — are to align with the Centers for Medicare & Medicaid Services’ (CMS) final rule that published in the Federal Register in November 2022. They will appear in the Information Management (IM), Leadership (LD), Medical Staff (MS), Provision of Care, Treatment, and Services (PC), and Rights and Responsibilities of the Individual (RI) chapters. However, until these new and revised EPs are incorporated into their appropriate chapters in Joint Commission survey technology, findings, along with the applicable Conditions of Participation (CoP) requirements, will be scored at standard LD.04.01.01, EP 2, until the fall interim standards release on Aug. 27.
View the prepublication standards. For questions regarding these revisions, please contact the Department of Standards and Survey Methods.
Beginning Aug. 27, an update will become effective for the Leadership (LD) requirement addressing ethical issues. The update does not introduce a new requirement or new expectations for compliance, but rather reinforces a longstanding expectation for accredited healthcare organizations.
EP 1 of the standard — LD.04.02.03: Ethical principles guide the [organization’s] business practices — now states: “The [organization] develops and implements a process that allows staff, [patients], and families to address ethical issues or issues prone to conflict.”
The update is to better reflect the intent of this element of performance (EP) for the following Joint Commission accreditation programs:
- Hospital
- Critical Access Hospital
- Ambulatory Care
- Behavioral Health Care and Human Services
- Home Care
- Laboratory
- Nursing Care Center
Questions regarding this revision can be directed to the Department of Standards and Survey Methods.
Ambulatory Buzz — Get the Most Out of Your Ambulatory Accreditation: Zach George, MBA, CPA, is the new executive director of Ambulatory Care Services at The Joint Commission. Previously, he was the director of Hospital Certification and also led business development for hospital, ambulatory, urgent care and other settings at The Joint Commission.
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