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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.
To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with new prepublication requirements on removing ligature (hanging) risks in rooms meant for suicidal patients. Several standards have been affected.
To keep themselves as closely aligned with CMS as possible, HFAP has updated their Acute Care Manual with a new requirement for Infection Control Standard 07.01.03—Reduce Risk of Legionella in Water Systems.
Almost two-thirds of the hospitals surveyed in 2017 were found noncompliant in at least one—and possibly many more—of the top 10 most challenging standards for hospitals.
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The ONC published the final 2016 Interoperability Standards Advisory (ISA) December 22, 2015. The final version includes structural changes available in the fall 2015 draft version. Each standard and implementation specification is assigned six informative characteristics that describe its maturity and adoptability. These informative characteristics will also allow the measures and standards to be tracked as they progress through updates and version, and the rate at which they are adopted, ONC said in a blog post.
The 2016 ISA has undergone significant changes from the 2015 version. These changes are largely attributed to the two rounds of public comment periods ONC conducted, as well as recommendations from the HIT Standards Committee, according to ONC. The most notable changes and additions are:
Other changes from the draft version include revisions and descriptions for the informative characteristics.
The 2016 ISA will serve as the basis for the 2017 version. The comment period to develop the 2017 version will begin early this year.
Examine all automatic door arrangements in light of the newest clarification on fire doors from CMS and revisions to The Joint Commission’s Life Safety standard on providing building features to protect against fire and smoke hazards.
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