Revisions to PI.01.01.01, EP 4

Effective immediately, The Joint Commission has revised Standard PI.01.01.01, EP 4 for ambulatory care, office-based surgery, critical access hospitals, and hospitals. Customers have expressed confusion with the requirement, which directs organizations to collect data on significant discrepancies between preoperative and postoperative diagnoses. The revision provides details and examples to further clarify the intent for this data collection requirement and how the data can be used in an organization’s performance improvement efforts regarding diagnostic errors. The revision also clarifies that the organization’s medical staff determine which unexpected postoperative diagnoses are clinically significant.

The revised requirement will publish online in the spring 2023 E-dition^® update to the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC), Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH), Comprehensive Accreditation Manual for Hospitals (CAMH), and Comprehensive Accreditation Manual for Office-Based Surgery Practices (CAMOBS). For those customers who purchase it, the spring 2023 CAMH hard-copy update service will include this revision.

Prepublication Standards:

• Ambulatory Health Care
• Critical Access Hospital
• Hospital
• Office-Based Surgery