Accreditation Updates

Revisions to  Standard MS.1.20 Approved

The Joint Commission Announces 2008 NPSGs
The Joint Commission has announced the 2008 National Patient Safety Goals and related requirements for each of its accreditation programs and its Disease-Specific Care Certification Program. The Goals and Requirements, recently approved by the Joint Commission's Board of Commissioners, apply to the nearly 15, 000 Joint Commission-accredited and certified health care organizations. Read more on the 2008 NPSGs.

New Leadership chapter effective January 1, 2009
Effective January 1, 2009, a revised Leadership chapter will be introduced for all accreditation programs. This chapter encompasses expectations regarding creation of a culture of safety; leadership accountabilities of the leadership groups, which hospitals may include the governing body, senior managers, management, and the leaders of the medical staff; management of disruptive behavior in those who work in the organization; and conflict management. The extended implementation period allows organizations to fully evaluate the standards and gives them more time to implement changes, if necessary. Portions of the standards have been in development for several years, including those addressing leadership accountabilities, the culture of safety and quality, and performance of organization-wide systems. The proposed changes for the chapter underwent two field reviews and multiple conversations with key stakeholders. Changes include:
 

• New standards derived from the work of the Leadership Accountabilities Task Force, such as those addressing shared leadership accountabilities, skills required of leaders, and communication among leaders.
• A new hospital standard that addresses conflict management.
• A new culture of safety and quality standard that addresses disruptive behavior for those who work in the organization.
• An increased emphasis on standards addressing the performance of important systems in the organization.
• A more explicit description of the roles of the leaders of the medical staff in addressing organization-wide issues.
• The introductory statements and relevant rationales emphasize the ultimate responsibility of governance.

The pre-publication standards for the revised Leadership chapter are now available.

Update on Standard MM 4.10 in the Emergency Department - MM.4.10 Task Force
To resolve the issue pertaining to MM 4.10 in the Emergency Department (ED):
 

• The Joint commission has convened an interdisciplinary Task Force to review the recommendations from stakeholders and the 2006 field review of Standard MM 4.10 EP 1 in the ED, and to develop a proposal for revisions to this standard. The American Medical Association is represented on the Task Force by Jay A. Gregory, MD, Vice Chair, Organized Medical Staff Section Governing Council.
• An additional field review is planned to obtain field input on proposed strategies to revise Standard MM 4.10 EP 1.

Free Audio Conferences
The Joint Commission is conducting free monthly one-hour audio conferences on topics of interest. All audio conferences (except the one for July 18) begin at 11 a.m. PT/noon MT/1 p.m. CT/2 p.m. ET. Information is sent to accredited organizations via list-serve approximately one week prior to each call. To sign up to receive registration information on upcoming audio conferences, go to your organization's extranet site on the Joint Commission Connect. Below is the schedule of upcoming audio conferences:

July 18              Standard MM 4.10: Review of Medication Orders in the ED
[Note different time for this audio conference: 9:30 a.m. PT/10:30 a.m. MT/11:30 a.m. CT/12:30 p.m. ET]
August 16         Strategic Surveillance System - Understanding Reports
September 13   National Patient Safety Goals
October 24        Inpatient Diabetes Certification
November 8      Hospital Leadership: Administration, Governance and Medical Staff Working Together
December 12    Transplant Center Certification

Facts about the Standards Improvement Initiative
In October 2006, The Joint Commission launched a Standards Improvement Initiative (SII) as part of its continuous efforts to improve the standards. The goal of this initiative is to:

• Clarify standards language
• Ensure that standards are program-specific
• Delete redundant or non-essential standards
• Consolidate similar standards

As additional benefit to users, the manuals will be reorganized and the scoring and decision process will be refined.

SII Timeline
October 2006:  The Standards Improvement Initiative was launched. The Joint Commission began seeking feedback through an on-line opinion survey and public comment on standards for the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation programs.

August 2007:  The Surveillance, Prevention and Control of Infection Control (IC), Improving Organization Performance (PI) and Management of Information (IM) chapters will be presented to the Standards and Survey Procedures Committee for approval.

June and November 2007:  "Virtual" pilot testing will take place with selected surveyors and Central Office staff.

First Quarter 2008:  The Joint Commission will begin conducting mock surveys using the improved standards and manuals.

May 2008:  The Joint Commission will begin seeking feedback through an on-line opinion survey and public comment on standards for the behavioral health care, laboratory and long term care accreditation programs.

June 2008:  Target date for completing improvements to the ambulatory, hospital, critical access hospital, home care and office-based surgery accreditation manuals. Begin standards improvements for the behavioral health care, laboratory and long term care accreditation programs.

January 2009:  Improvements to the standards are targeted to go into effect January 2009 for the ambulatory, critical access hospital, home care, hospital, and office-based surgery programs.

For more information, visit the SII for FAQs and other information. Questions may be sent to standardsimprovement@jointcommission.org, or contact Carol Gilhooley, Director, Division of Standards and Survey Methods, at (630) 792-5270.