JC quarterly update
The Joint Commission deletes 225 standards
by Jean S. Clark, RHIA, CSHA
The May 2016 issue of Perspectives outlined 225 hospital requirements from the accreditation manual?nine from the Information Management (IM) chapter and five from the Record of Care, Treatment and Services (RC) chapter?that have been deleted. This initiative is part of the Joint Commission’s project REFRESH and improving the survey process. Deletions fell into three categories:
1.Those that were duplicative of or implicit in the element of performance
2.Those that were a routine part of operations or clinical care processes
3.Those that were adequately addressed by external requirements
The largest number of deletions fell into those that were a routine part of operations or clinical processes. The good news is that we now have fewer standards/elements of performance to contend with. The bad news is that the majority of the IM and RC chapter deletions fell into the duplicative category, so we still have to be compliant in other standards. Let’s take a look at what was deleted and where requirements can now be located.
As you can see, the majority of the deletions are duplicative, which means the standards did not go away entirely. My advice is to review the deletions and compare your compliance with the referenced standard or requirement. Don’t become complacent just because some standards have been removed! And take time to review the other standards identified in the May 2016 issue of Perspectives, especially the Provision of Care deletions. The good news here is that all hospitals, regardless of deemed status, will be using the CMS restraints and seclusion requirements.
Editor’s note
Clark is a consultant, author, and speaker with more than 30 years of experience in HIM, accreditation, and regulatory compliance. Contact her at [email protected]. Opinions expressed are that of the author and do not represent HCPro or ACDIS.